Date copy mailed to parent: _______________________


SECTION 504/ADA ACCOMMODATION PLAN

Student's Name: _____________________________________   Birthdate: _________________
School: ____________________________________________   Grade: ___________________
Date of Meeting: _____________________________________   Review Date: ______________

1. Describe the nature of the concern: ________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. Describe the basis for the determination of handicap (if any): ______________________________
______________________________________________________________________________
______________________________________________________________________________

3. Describe how the handicap affects a major life activity: __________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Describe the reasonable accommodations that are necessary: ______________________________
______________________________________________________________________________
______________________________________________________________________________

Those present (Name and title):
___________________________________                 ___________________________________
___________________________________                 ___________________________________
___________________________________                 ___________________________________
___________________________________                 ___________________________________
___________________________________                 ___________________________________

I hereby acknowledge having been notified of my procedural rights under Section 504/ADA and having agreed to the contents of the plan.

___________________________________                 ___________________________________
Parent's Signature                                                            Date

cc: Student's Cumulative File

Attachment: Information Regarding Section 504 of the Rehabilitation Act of 1973.

DATE ADOPTED: JULY 1, 2003