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Section 504 Referral
This form is used to begin the process for the Section 504 Accommodation Plan.
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* Indicates required question
Student Name
Your answer
School
J.E. Ober Elementary School
Garrett Middle School
Garrett High School
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Grade
Your answer
Reason for Referral
Staff Recommendation
Parent
Other:
There is reasonable cause to suspect that this student has a disability that substantially limits one or more of the following major life activities:
*
Learning
Communication
Hearing
Self-Care
Vision
Motor/Movement
Other:
Required
Prior Referrals
Previous 504 Referral
Previous/Current Behavior Intervention Plan
Previous IEP
None
Presenting Concern: Please Describe
*
Your answer
Referral Completed by (Your Name)
*
Your answer
Your Relationship to Student:
*
Your answer
If you are not the parent, do the parents know about this 504 Referral?
Yes
No
Other:
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Additional Comments/Concerns:
Your answer
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