OFFENSE: (GS 115c-378) Misdemeanor violation of the North Carolina Compulsory
School Attendance Law
RESPONSIBLE PARTY: _______________________________________________________
RELATIONSHIP TO STUDENT: ________________________________
ADDRESS: __________________________________________________________________
CITY: _______________________ STATE: _______________________ ZIP: ____________
RACE: ______________________ SEX: __________________________ D.O.B.: _________
TELEPHONE: ________________________________________________________________
STUDENT’S NAME: __________________________________________________________
SCHOOL: ____________________________________________
STUDENT’S D.O.B.: _____________________ AGE: ________________ GRADE: ________
After conferring with the student and the person legally responsible for the student as named above it has been determined that
the person legally responsible for the student has not made good faith effort to comply with the provisions of N.C. General
Statue 115C et. Seq.
SCHOOL PRINCIPAL’S SIGNATURE ______________________________________________
DATE: ____________________
TOTAL NUMBER OF ABSENCES ____________ (Attendance Summary Included)
UNEXCUSED ABSENCES: __________________
EXCUSED ABSENCES: _____________________
File original with magistrate and send copy to Truancy Court Liaison
Alan D. Rutherford Educational Center * 410 Garfield Street * Statesville, NC 28677 * Phone: 704-832-2506 * Fax: 704-978-0078