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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