PARENT REQUEST FOR SECTION 504

EVALUATION

School:
Student:
Grade:

Date:
Date of Birth:

Parent:
Address:

Phone:

Referred by:
Position:
1. Reason for Request:
2. What major life activity is this impacting?
3. Has the student ever been referred, evaluated, and/or received services from special education?
Yes
No.
If yes, explain:

4. Attach any additional documentation.

______________________________________________________

_____________________________

Principals/Designee Signature

Date

Parent Signature

Date