Form 504-3 - Student Referral Form - Seattle School District
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1SEATTLE SCHOOL DISTRICT
STUDENT REFERRAL FORM
(FORM 504-3)
Student Name: ________________________________
Date: ________________________
Student ID #: __________________________________
Birth Date: ____________________
Student Address: _______________________________
City: Seattle
Zip: ______________
School: ______________________________________
Grade: _______________________
Parent(s)/Guardian(s) Name(s): ___________________________________________________
Parent(s)/Guardian(s) Telephone Number(s): ________________________________________
Parent(s)/Guardian(s) Email Address(es): ____________________________________________
1.
What mental or physical impairment(s) do you believe this student has? Please describe
the condition(s) and/or list information confirming the condition(s).
2.
Please describe how you think this mental or physical impairment is impacting this
student.
3.
What things do you think are needed to assist this student in being able to benefit from
his or her educational experience because of a mental or physical impairment?
4.
Please share any other information that you believe is relevant in determining if this
student should be evaluated for eligibility under Section 504?
FORM 504-3
Page 1
April 2014
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