Page Elementary 504 Eligibility Parent/Guardian Questionnaire
Email *
Student's First and Last Name: *
Parent/guardian completing this form: (First and Last Name)
 *
Please briefly describe the nature of your concern(s), e.g. academic, behavioral, gross/fine motor, social/emotional, medical, or other. *
During what time of the school day or during what subject areas is their performance impacted or limited? *
Does your child have a diagnosed condition that may relate to your concern(s).  If yes, please provide documentation by dropping off a copy of documentation to Page Elementary's office and/or emailing the documentation to jfunk-dieterle@tkschools.org.  *
Please indicate interventions, supports, or other actions tried prior to the referral in an effort to address the concern(s) identified above at home or at school.
 *
Has the student been referred, evaluated, or provided special education or 504 services before now?
 *
Which type of service was your child previously referred, evaluated, or provided? *
Is there anymore information you would like to share? Are there any specific accommodations you would like to trial in the classroom?  *
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