Notice And Consent To Evaluate Under Section 504 - Form 504 C printable pdf download

Notice And Consent To Evaluate Under Section 504 - Form 504 C

AIRBANKS

ORTH

TAR

OROUGH

CHOOL

ISTRICT

520 Fifth Avenue

Fairbanks, Alaska 99701-4756

(907) 452-2000

1 2

W W W

N O R T H S T A R

O R G

Notice and Consent to Evaluate Under Section 504 – Form 504 C

Date: _________________

To: ______________________________________

From: ____________________________________

This letter is to provide notice that the district proposes to evaluate

_____________________________________ and determine if he/she is eligible for services

under Section 504 of the Rehabilitation Act of 1973.

The team has concluded that the following assessments are necessary to determine if your child

has a disability under Section 504 and needs a Section 504 Accommodation Plan:

Your written consent is necessary because this is a(n):

 Initial Evaluation

 Reevaluation

 Review of existing data

You will be invited to participate in a meeting to review the evaluation results and to determine

if your child is eligible for a Section 504 Accommodation Plan.

PARENT CONSENT

I understand that the granting of consent for evaluation is voluntary.

 Consent to evaluate is given

 Consent to evaluate is denied

__________________________________

_____________

___________________

Parent/Guardian Signature

Date

Phone

For questions, please contact ____________________________ at _________________

Thank you for working with the district to provide appropriate services for your child.

For Staff Use:

Date Received

Received By: (initial)

9/13

Notice And Consent To Evaluate Under Section 504 - Form 504 C

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