504 Form G - Accomodation Plan

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504 FORM G
WALWORTH SCHOOL DISTRICT
SECTION 504 ACCOMMODATION PLAN
School Year _____ - _____
Case Coordinator __________________________
Name ___________________ DOB: __/__/__ Age _____ School ____________________________________________ Grade _________
Phone __________________ Date of Meeting ___/___/___ Initial Plan ___/___/___ Parent Notification of Meeting ____/____/____
This plan will be in effect from ___/___/___ to ___/___/___. This plan is to be reviewed no later than ___/___/___ Disability_____________
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Presenting Concerns
Accommodations or Services
Person(s) Responsible
______________________________
_______________________________
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______________________________
_______________________________
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______________________________
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______________________________
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Signature of Participants
Position
Date Signed
______________________________
___Parent/Legal Guardian__________
_______________________________
______________________________
___504 Building Coordinator________
_______________________________
______________________________
___Teacher_____________________
_______________________________
______________________________
_______________________________
_______________________________
______________________________
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______________________________
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Parent Authorization for Section 504 Plan
 I give permission for my child to receive accommodations or services described in this 504 plan. ___________________
__________
Signature of Parent(s)/Guardian(s)
Date
 I do not give permission for my child to receive accommodations or services described in this 504 plan. ________________ __________
Signature of Parent(s)/Guardian(s)
Date
2/12
Section 504 Accommodation Plan
(504 FORM G)

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