Section 504 Preliminary Referral Form

Section 504 eligibility requires the presence of a disability that substantially limits a major life activity (e.g. learning). Section 504 is a federal anti discrimination law that grants rights for students with disabilities to be free from discrimination.

Full Name of Student Being Referred:required

Grade:required

Full Name of Person Making Referral:required

Date of Referral:required (mm/dd/yyyy)

Reason for Referral (include major life activity that is being affected **see below):required

Strategies/Interventions to Date (please attach relevant information):required

If the preliminary referral is made by a parent/guardian, we will be providing you with a Section 504 of the Rehabilitation Act of 1973 Parent Referral Packet that will need to be successfully completed. Please be informed that the packet will require a medical note from your child’s physician.

** Major life activities include, but are not limited to, functions such as self-care, performing manual tasks, walking, seeing, hearing, speaking, breathing, concentrating, interacting with others, learning and working