This form is used to request a student be re-evaluated to determine continued eligibility under Section 504. Please complete the form below

IF A STUDENT DOES NOT CURRENTLY HAVE A 504 PLAN, DO NOT COMPLETE THIS FORM.

Once the form is completed, the District 504 Coordinator will process the request in a timely manner.

If you have any questions about this process, please contact your school's 504 Designated Person.

Email address *
General Information
Person Requesting Re-Evaluation *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's School *
Requested Information
Please answer the following question as thoroughly as possible.
Reason for Request *
Your answer
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This form was created inside of Tippecanoe School Corporation.