Page Elementary 504 Eligibility Parent/Guardian Questionnaire

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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. *

Yes

There is a suspected condition but not an outside medical diagnosis

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?
*

Yes

Which type of service was your child previously referred, evaluated, or provided? *

Special Education (IEP)

504 Plan

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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This form was created inside of Thornapple Kellogg Schools.