Section 504 Parent Referral Form

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Section   5 04   P arent   R eferral   F orm  
 
For   O ffice   U se   O nly  
Department   o f   S pecial   E ducation   a nd   S tudent   S ervices  
HOWARD   C OUNTY   P UBLIC   S CHOOL   S YSTEM  
Date   R eceived  
Ellicott   C ity,   M D   2 1042  
 
                    /  
    /  
 
   
 
Date:
/
/
Student Name:
Grade:
Date of Birth:
/
/
School:
 
Dear Parent/Guardian,
You requested that your child be referred to the Section 504 team. For your convenience you may complete this
form and return it to your child’s guidance counselor. Any other form of written referral will also be accepted.
Once your written referral is received, a Section 504 team meeting will be schedule for your child.
Parents/Guardians will be invited to attend.
What is Section 504?
Section 504 of the Rehabilitation Act of 1973 is a federal law that protects the civil rights of individuals with
disabilities. The Act prohibits any organization that receives federal funds from discriminating against otherwise
qualified individuals because of disability.
The Howard County Public School System’s elementary and
secondary programs and activities are subject to the provisions of Section 504. A student should be considered
for eligibility for a Section 504 plan if he/she has a physical or mental impairment that may substantially limit one
or more major life activities.
Section I.
Check any area(s) of concern for your child:
Learning
Speaking
Major Bodily Functions
Reading
Seeing
Caring for Oneself
Mathematics
Hearing
Performing Manual Tasks
Thinking
Breathing
Other:
Concentrating
Eating
Walking
Sleeping
Section II.
Describe your concerns as compared to the average student in the general population. Please attach any report(s)
from your child’s physician, therapist, etc. you wish the 504 team to consider.
Additional space on Page 2
Distribution: Student Record
Page 1   o f   1
February 2014

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