Mansfield Township School District
STUDENT RECORD REQUEST FORM
Student Name: ___________________________________________________________________________
Date of Birth: ______________________________________ Date Withdrawn: ____________________
Grade Level at time of withdrawal: (circle level)
PreK 3 PreK 4
K 1 2 3 4 5 6
Transferring from: _______________________________________ Phone: _____________________ Fax:___________________
Street Address: __________________________________________
State: ______________ Zip: ____________________
I hereby authorize Mansfield Township School District to obtain the following information concerning the above named student. I certify that all information provided is true to the best of my knowledge.
Pursuant to public law regulating the release of school records, we as officials of a public School are requesting:
o Birth Certificate
o Report Cards
o Standardized test results
o Health/Immunization records including most recent physical
o Discipline records
o Withdrawal papers/State Transfer Card
o Special Education records and copy of IEP
o ALL OF THE ABOVE
Please forward this information to the address listed below.
We appreciate your assistance.
PreK – Gr. 2Gr. John Hydock Elementary School Mansfield Township Elementary 19 Locust Avenue
Gr. 3-6 200 Mansfield Road East Columbus, NJ 08022 Columbus,