Massachusetts Transfer Card
State-Assigned Student Identifier No. (SASID)_____________________________ Grade___________ Date___________________
Locally-Assigned Student Identifier No. (LASID)___________________________ Gender___________
Name_______________________________________________________________ Date of Birth___________________________
Last First Middle (No Initial) Year Month Day
City/Town of Birth________________________________________ City/Town of Residence______________________________
Parent or Guardian____________________________________________________________________________________________
Special Needs Yes (If “YES” new school system must contact old school system to assure continuation of special education program.)
No
IMMUNIZATION
|Number of Doses |DTP/DTaP_____ |Polio____________ |MMR___________ |Hepatitis B_______ |Varicella____________ |
| | | | | | |
|Date of Last Dose |Date__________ |Date_____________ |Date____________ |Date_____________ |Date_______________ |
| | | | | | |
| | | | | |Physician certified history of |
| | | | | |Varicella____________ |
| | |Date of Last Physical Exam | | |
|Date of Last Lead Screen |Date_____________ | |Date_____________ | |
*Requires medication administration during the school day. ______Yes _______No. If yes, school nurse from new school system must contact former school nurse to assure continuation of service delivery.
Residence Before Transfer______________________________________________________________________________________
Street City/Town State
School______________________________________________________________________________________________________
Name Street City/Town State
Principal_____________________________________________________School Telephone_________________________________
New Residence_______________________________________________________________________________________________
Street City/Town State
New School System___________________________________________________________________________________________
Massachusetts Transfer Card New Superintendent Old Superintendent Student
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