Transcript Release Form-Former Students

[Pages:1]Clarkstown High School South School Counseling Center 31 Demarest Mill Road West Nyack, NY 10994

845-624-3413 845-624-3418 Fax

Transcript Release Form-Former Students

___________________________ Date

___________________________ Telephone #

Date of Graduation _______________________

OR

Last Attended

_______________________

________________________ ___________________________

Date of Birth

Social Security #

_______________________________ ____________________________ ___________________________

Last Name

First Name

Maiden Name

________________________________________________________________________________________

Address

City

State

Zip

Are you requesting SAT scores be sent? (If they have been released to South HS by you)

Yes

No

Please send a copy of my records to: (Please give full address of college/university)

____________________________________________ Student or Guardian's Signature

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