Eccs Referral Form Section 504 Plan
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1Referral Form Section 504 Plan
Section 504 of the Rehabilitation Act of 1973 is designed to eliminate discrimination on the basis of disability in
any program or activity receiving Federal financial assistance. Students eligible for assistance are those who:
1) have a physical or mental impairment which substantially limits one or more major life activities,
2) have a record of such impairments, or
3) are regarded as having such impairment.
If your child is currently receiving special education services, a 504 Referral is not necessary. If you feel the
student identified qualifies for assistance under Section 504, please complete the following information.
Student:
Grade:
School:
Date:
DOB:
Sex:
F
M
Parent(s):
Home Phone:
Work Phone:
Primary Language of the home:
English
Other:
Name of person submitting referral:
Position:
Describe the student’s suspected handicapping condition:
Documentation of the child’s handicapping condition has been:
Enclosed
Requested from:
The student has a physical or handicapping condition, or is regarded as having such, which substantially limits
major life activities including but not limited to (without regard to mitigating measures):
Caring for One’s Self
Breathing
Communicating
Digestive
Performing Manual Tasks
Learning
Thinking
Bowl/Bladder
Walking
Working
Immune System
Endocrine
Seeing
Reading
Neurological
Other:
Hearing
Standing
Circulatory
Speaking
Concentrating
Respiratory
Received by Teacher: _______________
Received by Section 504
Building Coordinator: _______________
Revised 12/10
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