ICCSD Section 504 Parent/Guardian Referral Form

Required

Section 504 of the Rehabilitation Act of 1973 is designed to eliminate discrimination on the basis of disability in any program or activity receiving Federal financial assistance. If you feel your student may have an impairment that substantially limits a major life activity (for example, learning, reading, concentrating, communicating, or functions of bodily systems), please complete the following information and submit it to the school’s 504 Coordinator. Once received, the school 504 Coordinator will begin the process to determine if the student is eligible under Section 504. Parents will participate in the 504 team meeting to determine eligibility

Student Namerequired

First Name

Last Name

Schoolrequired

Graderequired

Date of Birthrequired

Parent/Guardian 1 Namerequired

Phone Numberrequired

Parent/Gurdian 1 Emailrequired

Parent/Guardian 2 Name

Phone Number

Parent/Gurdian 2 Email

Describe the reason for the referralrequired

Mental or Physical impairment, or suspected impairmentrequired

Major Life Activities Possibly impacted (ex. - eating, breathing, learning, hearing, etc)required

List any formal medical diagnoses: (a formal diagnosis is not required for section 504 referral or eligibility)

Is the student currently taking medication for the impairment?required

Yes

If yes, what are the impacts of the medication on the students (positive or negative)

Please list any additional measures that may positively impact the student in school (ex. - health plan, assistive technology, behavior plan, etc)

Attach any supporting documentation that you would like the 504 team to review, including medical records, evaluations, etc.

Attach up to 5 files with a maximum size of 10MB

No file chosen

Daterequired

Must contain a date in MM/DD/YYYY format

Please complete the security verification below.

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ICCSD Section 504 Parent/Guardian Referral Form

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