Section 504 Plan Request For A Child With Asthma
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1
2Section 504 Plan Request for a Child with Asthma
Date:
Current School:
_______________________________
_____________________________________________________________________________________________
Student’s Name:
Date of Birth:
___________________________________________________________________________________
_______________________________
Student’s Address:
Phone Number:
_______________________________________________________________________________
_______________________________
Dear School Administrator,
Pursuant to Section 504 of the Rehabilitation Act of 1973, I am writing to request an individualized evaluation on behalf of my child, who is diagnosed
with asthma, to determine what services and modifications are necessary to include in a 504 Plan. In addition to a 504 evaluation, I am requesting that
the following accommodations be made for my child’s health condition while at school and school-sponsored activities:
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My child may carry quick-relief asthma medication at all times during school hours and school-sponsored activities.
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My child can self-administer quick-relief asthma medication without assistance.
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My child’s quick-relief asthma medication is to be administered to him/her during school hours.
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My child may not be able to participate fully in P.E. activities and may need modified P.E. activities.
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My child must be allowed to self-monitor his/her activity level with rest periods as needed, including during P.E. activities.
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My child must have early access to the building when temperatures or wind chill are below 25ºF or above 85ºF.
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My child cannot participate in outdoor P.E. or other outdoor activities when temperatures or wind chill are below 25ºF or above 85ºF.
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My child must have unlimited access to the restroom and access to water for hydration as needed.
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My child must be allowed access to the school elevator (if one is available) when necessary due to breathing problems.
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My child needs an individual locker.
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My child needs an extra set of books for home use.
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My child needs intermittent homebound services due to frequent absences.
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My child’s asthma is triggered by school/classroom conditions and they need to be controlled as follows:
All fur/feather bearing pets need to be removed from child’s classrooms
____
My child should not sit near the chalkboard
____
My child should not sit near open windows
____
*
Notify parent/guardian before any dusted or sprayed pesticide application and before any construction or remodeling projects
____
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Any Additional Modifications Needed:
__________________________________________________________________________________________________
I have attached the following documents and am requesting that they be attached to the 504 Plan:
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My child’s Asthma Action Plan
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Medical Provider Documentation
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If Self-Administering:
Asthma Prescription Label
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Parent Request for Self-Administration of Medication
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If not Self-Administering:
Physician Request for Administration of Medication to Student
□
Parent Request for Administration of Medication to Student
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Other
__________________________________________________________________________________________________________________________________
I look forward to developing a 504 Plan with you. Thank you for your assistance.
Sincerely,
____________________________________________________________________
____________________________
Parent/Guardian Signature
Date
TO BE COMPLETED BY SCHOOL STAFF:
I,
, acknowledge that on the date below I received a copy of this 504 Request.
_________________________________________________________
_______________________________________________________________________________________
_________________________________
Signature
Date
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