This form is used to submit a request for an initial evaluate under Section 504 of the Rehabilitation Act of 1973.

Once this form is completed, the District 504 Coordinator will process the request in a timely manner.

If you have any questions about the Section 504 process, please contact your school's 504 Designated Person.

Email address *
General Information
Person Making Referral *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's School *
Referral Information
Please answer the following questions about the student you are referring as completely as possible. The information will be used to determine whether an evaluation will be initiated. If you have questions, please contact your school's Section 504 Designated Person.
Please describe the mental or physical impairment you suspect affects the student (e.g., ADHD, Anxiety, migraines, etc.)? *
Your answer
Please describe how the suspected impairment impacts the student. *
Your answer
Please describe any accommodations you believe are required or you are currently using because of the impairment. *
Your answer
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This form was created inside of Tippecanoe School Corporation.