SCHOOL NAME

Date: Click or tap here to enter text.	Initial Evaluation Re-evalulation

Student Name: Click or tap here to enter text.Grade: Click or tap here to enter text. DOB: Click or tap here to enter text.

Parent/Guardian Name(s): Click or tap here to enter text. Phone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Dear Parent/Family Member/Guardian:

A Section 504 Evaluation typically consists of a review and interpretation of information from a variety of sources (i.e. existing educational records, staff reports/observations, grades, standardized test results, prior testing, and other data) in order to determine if your child qualifies as a student with a disability under Section 504.

Consent for Section 504 Evaluation: We request your written informed consent for a Section 504 evaluation as described above.

If you CONSENT to the Section 504 evaluation, please mark the appropriate CONSENT box below, sign, date and return to the school Section 504 contact below.

If you DO NOT CONSENT to the Section 504 evaluation, please mark the appropriate DO NOT CONSENT box below, sign, date and return to the school Section 504 contact below.

Click or tap here to enter text.

Site Section 504 Coordinator-Printed Name

Click or tap here to enter text.

Phone/email

☐ I CONSENT to a Section 504 evaluation.

☐ I DO NOT CONSENT to a Section 504 evaluation.

_______________________	____________________	________________

Parent/Guardian Signature	Parent/Guardian Printed Name	Date