Student Transition Form

Student Transition Form

Purpose: This Student Transition Form documents the transfer of the student’s educational program and records from the current school to the receiving school, identifies current services and special education status, and provides the authorizations required to effect transfer of records and placement decisions. Completion of this form facilitates continuity of instruction, supports placement and IEP/504 implementation where applicable, and confirms parental or adult student consent for release of records.

Student Information

Student Name:

Date of Birth:     Student ID:

Parent / Guardian or Adult Student

Current School Information

Last Date of Attendance:

Receiving School / Placement

Intended Start Date at Receiving School:

Reason for Transition (check all that apply)

Change of residence    Program placement/change    Parent/Student choice

Disciplinary transfer    Other (specify below)

Educational Records to be Transferred

The undersigned authorizes release of the student's education records described below to the receiving school. Records requested:

Academic transcript    IEP / special education records    504 plan

Attendance records    Health / immunization records    Standardized test scores

Discipline records    Other (specify)

Special Education / Accommodations

IEP in effect: Yes    No

Related services currently provided (check all that apply):

Speech/Language Therapy    Occupational Therapy    Physical Therapy

Counseling    Other

Academic and Behavioral History

Has the student received disciplinary sanctions in the last 12 months?    Yes    No

Health / Medical Information

Medication administered at school: Yes    No

Emergency Contact

Authorizations and Certifications

By signing below, I certify that I am the parent or legal guardian of the student named above, or the student if 18 years of age or older, and I authorize the release and transfer of the educational records and information identified on this form from the current school to the receiving school. This authorization includes but is not limited to academic records, IEP/504 documentation, health and immunization records, attendance, standardized test scores, and discipline records as indicated. I understand that release of certain records may be required to ensure appropriate placement and services at the receiving school.

I attest under penalty of perjury that the information contained in this form is true and correct to the best of my knowledge. I understand that submission of this form effectuates the transfer request and that the current school will process records in accordance with district policies and applicable education privacy obligations.

I consent to the release of records and placement information as requested above.

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