FORM A - Section 504 Referral

This form is to be completed by the school personnel, parent, or other individual referring the student for an evaluation to determine the student's eligibility under Section 504 of the Rehabilitation ct of 1973.  The individual completing this form should provide the requested information to the best of his or her ability.  Additional pages may be added to this form if needed.  Any questions regarding the completion of this form should be directed to the below-designated Section 504 Coordinator.  
Signature of Person Initiating Referral *
Powered byFormsite