504 Eligibility And Accommodations Form Page 4

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7. Signatures of Participants
I agree with the 504 Eligibility Determination as noted above:
Role / Title
Print Name
Signature
Date
Parent / Guardian
Student (if present)
Administrator
Case Manager
Discussed w/ Parent or Guardian on the phone
8.
PARENT/STUDENT RIGHTS IN IDENTIFICATION, EVALUATION AND PLACEMENT
A copy of Parent/ Guardian Student Rights was given to___________________________________
on _____________, by________________________________________________.
1. Place a copy of this 504 Eligibility Determination in the student's academic file.
2. Send a copy of this 504 Eligibility Determination to:
District 504 Coordinator, Bethel School District Office, 4640 Barger Dr. Eugene, OR. 97402-1239
9. If Parent/ Guardian Disagrees:
 I do not agree with the 504 Eligibility Determination as noted above, and I have received a
copy of my Parent/Guardian rights including the right to request a Review Hearing.
The person in this
district responsible for assuring that the district complies with Section 504: Chris Parra, (541-689-3280)
Parent/Guardian Signature______________________________________ Date_______________

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