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RHS 504 Evaluation Request Form
1. This form is to be completed by a student, guardian or staff member who would like to refer themselves or their student for a 504 accommodation plan.
2. Please complete all sections and questions within this form with as much detail as possible.  This will help our Coordination of Services Team (COST) better understand the needs and strengths of the student.
3. Submission of this form will start the process for assessment and if warranted, a 504 eligibility meeting.

The process for requesting a 504 accommodation plan begins with completing this form.  Once completed, the information provided will be reviewed at one of our bi-monthly COST meetings.  This team is made up of administrators, counselors, school physiologist(s), mental health therapist(s), Intervention Coordinator, and our Wellness Coordinator.  This team will review all relevant information pertaining to the student including information provided in this form, reports from outside entities, teacher feedback, grades, attendance, standardize tests, and more.  

The purpose of this team is to determine if a student qualifies for a 504 assessment/eligibility meeting.  The team is looking at three main qualifications including 1.) A diagnosed physical or mental impairment, 2.) The impact of the impairment within the learning environment and 3.) Whether or not the impairment substantially limits the students ability to equitably access the curriculum.  

If the information reviewed meets the three qualifications an eligibility meeting will be scheduled with our 504 Team (Admin, counselor, general education teacher), a guardian and the student.  If the information reviewed does not meet the three qualifications then a "No Letter" will be sent explaining that the student did not meet the qualifications for an assessment.  This letter will also include a summary of all of the feedback reviewed and will provide other recommendations for support and informal accommodations accessible to the student on campus.

Please contact your students Assistant Principal or counselor if you have any questions.  Thanks. 

Please continue to the next section to begin your request.      
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What is your name?
What is your contact number and email address?
What is your relationship to the student?
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What is the name of the student that you are requesting a 504 evaluation for?
Student Grade Level
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Select the student's school counselor
What is the student's disability that is limiting one of life's major functions including learning?
How does the student's disability impact the student?
Do you have a diagnosis or other assessment or evaluation regarding your request? 
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How might a 504 plan help the student?
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