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.

Person Referring *

Email Address of Person Completing Form *

Please re-enter email address *

Student's Complete Legal Name *

Date of Birth * +

Sex *

Grade *

School *

Parent or Legal Guardian *

Phone Number *

Address *

Email Address *

Please re-enter email address *

Describe the Reason(s) for the Referral *

Describe the Student's physical or mental impairment(s) and resulting limitations. *

List the Major Life Activity (or Activities) of Student impacted by his or her impairment. *

Identify any mitigating measures currently in use or provided for the Student's benefit. (Mitigating measures may include medication; medical supplies; equipment or appliances; low-vision devices, which do not include ordinary eyeglasses or contact lenses; prosthetics, including limbs and devices; hearing aids and cochlear and other hearing devices; mobility devices; oxygen therapy equipment and supplies; use of assistive technology; reasonable accommodations or auxiliary aids or services; and learned behavioral or adaptive neurological modifications medication.) *

Signature of Person Initiating Referral *

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