This form is used to request a student be re-evaluated to determine continued eligibility under Section 504, to reconsider eligibility for a student evaluated within the last year and found not eligible, or when a significant change in placement is being proposed for a student with a current 504 plan. If one of these apply, please complete the form below

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 *
Student's Last Name *
Student's School *
Requested Information
Please answer the following question as thoroughly as possible.
Reason for Request *
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This form was created inside of Tippecanoe School Corporation.