504/HHB Hospital Homebound Eligibility Request 
This form is a request for eligibility and/or evaluation for 504/HHB services.  Upon completion, the appropriate forms will be sent to the parent/guardian at the email provided.  All information received will be held confidential and reviewed by the 504 coordinator and authorized district representatives.
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Today's date *
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YYYY
Parent/Guardian email *
Parent/Guardian ten digit phone number *
Are you requesting 504 or HHB services? *
Briefly describe the nature of the student's disability/limitations. *
Student's Last Name, First Name *
Student Number *
Student's current grade level *
504 coordinator will contact you by email upon receipt of this information. For questions please contact: 
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