Sample 504 Plan Template
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There is no standard 504 plan for schools to use. This form shows you an example of what could be included in a 504 plan.
A 504 plan should be tailored to your child’s needs.
Keep in mind the school is allowed to use its own form or not use a written 504 plan at all. In these cases, you can still use
this sample plan to take notes and organize your thoughts.
School Name:
Student Name:
Date of Birth:
Grade:
Qualifying Disability:
Date Plan Written:
Date Plan Goes Into E ect:
Date Plan to Be Reviewed:
Documentation of Disability (see attached):
504 Team Members
Title
Contact Information
Administrator
General education teacher
Related service provider
Parent
Other:
Other:
TEACHER EDUCATION AND SUPPORT
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