PN referral form

Name and Designation of Referrer                                                                                                               
Child's full name                                                                                                         
Child's date of birth 
Full name of Mother (or Carer) 
Full name of Father (or Carer) 
Parent(s) phone number 
Period of absence for which penalty notice is requestedFrom                                            To                                             
Checklist of information for referral to ACE for consideration of the issuing of a penalty noticeTick       
Referral meets the threshold for consideration for issuing of a Penalty Notice in terms of Penalty Notice Code of Conduct? (Section 3) 
Attendance printout for previous and current years attached 
Referral for Penalty Notice is in relation to a persistent absence rate of below 85% unauthorised absence over a six week period 
Parent/carer has taken child out of school for leave in term time without the permission of school staff 
School considered history of previous leave taken in term-time and previous attendance rate 

Evidence of action undertaken by school staff to resolve the attendance issues to be attached - including copies of any communication to and from parents, original application for exceptional leave from parent/carers where applicable, letters/documents from parents, attendance contracts, etc

Evidence attached of consultation with other professionals involved should be attached 
Attendance details of siblings - where appropriate 

Please provide summary of action school took before and after pupil returned to school (eg: phone conversation or meeting with family):




Please provide summary of parent/guardian response:




ACE will respond to requests within 10 school days of receiving the request for consideration of a penalty notice.