Wallkill Valley Guidance Department

John J. Mayer

Director of Student Personnel Services

______Transcript Request ______Health Record Request

PLEASE ALLOW 5-7 DAYS FOR PROCESSING

Name of Student _________________________________________________

Maiden Name __________________________________ *Date of Birth ___________________

Address while attending WVRHS _________________________________________________

*Year of Graduation _______________________________

Year of Withdrawal from WVRHS ___________________________________

Send Transcripts to (Please include addresses):

_______________________________ ________________________________

_______________________________ ________________________________

_______________________________ ________________________________

*Signature ________________________________________ Date: ________________________

I do hereby swear under penalty of law that I am the student listed above and have legal

Right to these records.

Present Address: _______________________________________________________________

Phone Number: ___________________________________

*Required Fields

***Please note: if you are requesting an official copy of the transcript, it must be send directly

To a school, employer, or organization. It cannot be send to an individual.

Date Sent from Guidance Office: _________________________________________

Wallkill Valley Regional Guidance Department

10 Grumm Road

Hamburg, NJ 07419

Phone: 973.827.4100

Fax: 973.827.0094