Referral for Section 504 Evaluation
This form is to be used for students who are referred for an initial 504 evaluation to determine if they have a disability that is impacting one or more major life activities. 
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Email *
What is the student's first and last name? *
Who is referring the student for a Section 504 evaluation? *
Who is the student's counselor/ advisor? *
What grade is the student in? *
Please describe the suspected disability. Include any known medical diagnoses.  *
Please describe the impact of the suspected disability on the student's daily life, including how they access their education.  *
Is there other information the Section 504 evaluation team should know?
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