Educational Support 504 Plan

Educational Support 504 Plan

Parties and Identifying Information

School / District Name:

Student Name:    Student ID:

Date of Birth:    Grade:

School Site / Program:

Parent / Guardian Name:    Contact Phone:

School Representative:    Title:

Recitals

WHEREAS, the School identified above provides educational programming to the Student named above and, pursuant to Section 504 of the Rehabilitation Act, is responsible for considering reasonable accommodations to ensure equal access to educational opportunities; and

WHEREAS, the Parent / Guardian has requested evaluation and implementation of accommodations appropriate to the Student's documented disability or functional limitation described below; and

WHEREAS, the Parties agree to adopt this Educational Support 504 Plan to memorialize the accommodations, services, implementation responsibilities, monitoring procedures, and the administrative terms that will govern provision of covered supports.

Identification and Eligibility

504 Eligible    Not Eligible    Date of Evaluation:

Scope of Work

The School will provide the following services, accommodations, and operational responsibilities described below to ensure the Student's access to their educational program:

Accommodations and Modifications

The following accommodations will be implemented where appropriate. Check all that apply and provide details as necessary.

Extended time for assignments and tests
Preferred seating
Scheduled/frequent breaks
Provision of notes or a note-taker
Use of assistive technology (specify below)
Other (specify below)

Support Services and Responsible Staff

Provide staff responsibilities and frequency for delivery of accommodations and services.

Assessment, Grading, and Testing Modifications

Implementation, Monitoring, and Review

Effective Start Date:    Scheduled Review Date:

Parent / Guardian Participation and Consent

I acknowledge that I have participated in the development of this plan and understand the accommodations described. I hereby:

Provide consent for implementation of this 504 Plan    Do not consent at this time

Payment Terms (If Applicable)

Some auxiliary or contracted supports may carry costs. Indicate whether payment by the Parent / Guardian is required and specify terms below.

Payment required    No payment required

Term and Termination

This Plan is effective as of: and shall remain in effect until: unless earlier revised or terminated in accordance with the notice provision below.

Notice Period for Termination by Either Party:

Confidentiality

All records and information generated in connection with this Plan shall be treated as education records to the extent governed by applicable law. The School and Parent / Guardian agree to maintain the confidentiality of the Student's records and to distribute information on a need-to-know basis. Any release of personally identifiable information from the Student's records shall be made only with written consent or as otherwise permitted by law.

Governing Law

This Plan shall be interpreted and enforced under the laws of the state of to the extent not preempted by federal law.

Entire Agreement

This document constitutes the entire agreement between the Parties concerning the Student's 504 accommodations and supersedes all prior written or oral agreements related to the subject matter hereof. Any amendment to this Plan must be in writing and signed by the Parent / Guardian and an authorized School Representative.

Acknowledgment

By signing below, the Parties certify that they have discussed the contents of this Plan, that the information contained herein is accurate to the best of their knowledge, and that they understand their responsibilities for implementation, review, and confidentiality as described above.

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