AGE: / Date of 504 Meeting:
REASON FOR MEETING
Initial / Periodic Reevaluation / Reevaluation Before Significant Change In Placement / CURRENT
GRADE: / Choose a GradeKPre-KESCE1st2nd 3rd4th5th6th7th8th9th10th11th12thAbove 12th Not School AgeHeadstart
Student’s Full Name
Current School: / Choose the Appropriate SchoolAlternative EducationBluestone Middle SchoolBluestone High SchoolChase City ElementaryClarksville ElementaryLaCrosse ElementaryPark View Middle SchoolPark View High SchoolSouth Hill ElementaryHeadstartRivermontResidentialResidential - GraftonResidential - The PinesResidential - Whisper RidgeResidential - New DominionResidential - HallmarkResidential - Jackson Field HomeFaison SchoolResidential - Liberty PointResidential - Keystone MarionResidential - Blandford ManorHope Haven / Projected School: / SAME AS CURRENT SCHOOLAlternative EducationBluestone Middle SchoolBluestone High SchoolChase City ElementaryClarksville ElementaryLaCrosse ElementaryPark View Middle SchoolPark View High SchoolSouth Hill ElementaryHeadstartRivermontResidentialResidential - GraftonResidential - The PinesResidential - Whisper RidgeResidential - New DominionResidential - HallmarkResidential - Jackson Field HomeFaison SchoolResidential - Liberty PointResidential - Keystone MarionResidential - Blandford ManorHope Haven
Parent/Guardian Name: / Cell Phone:
911 Home Address: / City, State, Zip CodeBaskerville, VA 23915Boydton, VA 23917Bracey, VA 23919Brodnax, VA 23920Buffalo Junction, VA 24529Chase City, VA 23924Clarksville, VA 23927Ebony, VA 23845Fort Mitchell, VA 23941Lacrosse, VA 23950Nelson, VA 24580Red Oak, VA 23964Skipwith, VA 23968South Hill, VA 23970Virgilina, VA 23964 / Phone # (H):
Mailing Address
(If Different): / City, State, Zip CodeBaskerville, VA 23915Boydton, VA 23917Bracey, VA 23919Brodnax, VA 23920Buffalo Junction, VA 24529Chase City, VA 23924Clarksville, VA 23927Ebony, VA 23845Fort Mitchell, VA 23941Lacrosse, VA 23950Nelson, VA 24580Red Oak, VA 23964Skipwith, VA 23968South Hill, VA 23970Virgilina, VA 23964 / Phone # (W):
Date of 504 Eligibility Meeting
Date of Next 504 Reevaluation (no later than 3 years from date of initial 504 Eligibility meeting)
Date of 504 Plan
This 504 plan will be reviewed no later than a year from the date of initial meeting.
Date parent notified of 504 meeting
Date student notified of 504 meeting
School 504 Coordinator / Phone #
District 504 Coordinator / CHRISTY PEFFER / Phone # / 434.738.6111 x240
Referring Source / Phone #
REASON FOR THE REFERRAL
REASON FOR THE REFERRAL:
LIST AREAS OF CONCERN IN CLASSROOM PERFORMANCE:
LIST ANY PRE-REFERRAL INTERVENTIONS BEING IMPLEMENTED IN THE CLASSROOM (REQUIRED):
DIAGNOSIS BY A HEALTHCARE PROFESSIONAL (LIST DR. & DIAGNOSIS) IF APPLICABLE:
REVIEW OF CURRENT EVALUATIONS/SCREENINGS IF APPLICABLE:
AREA TESTED / EVALUATION TOOL / EVALUATION ADMINISTERED BY: / DATE / FINDINGS:
DO CULTURAL, ECONOMIC, AND/OR ENVIRONMENTAL FACTORS ACCOUNT FOR THE LEARNING PROBLEMS?
IF YES, EXPLAIN BELOW: / YES / NO
ANY OTHER INFORMATION:
ELIGIBILITY CRITERIA AND DETERMINATION
1. / STUDENT HAS A MENTAL OR PHYSICAL IMPAIRMENT / YES / NO
If YES, state the nature of the mental or physical disability and continue to question #2.
If NO, the student is NOT ELIGIBLE for a 504 Plan.
2. / STUDENT’S IMPAIRMENT SUBSTANTIALLY LIMITS A MAJOR LIFE ACTIVITY / YES / NO
If YES, the student continues to be eligible for a 504 Plan;
If NO, STOP, the student is NOT ELIGIBLE for a 504 Plan. Present parents with a copy of their rights.
COMMITTEE DECISION:
The student no longer has a disability that requires Section 504 services within the school environment.
The student continues to have a disability that requires Section 504 services within the school environment.
Continue with current Accommodation Plan.
Modify the current Accommodation Plan.
PARTICIPANTS INVOLVED IN 504 MEETING:
NAME OF PARTICIPANT / RELATIONSHIP TO STUDENT
PARENT RIGHTS FOR SECTION 504 were (circle one) handed mailed offered to parent(s).
PARENTAL /ADULT STUDENT AGREEMENT FOR DISMISSAL OF THE 504 PLAN(This section is only completed if the student has been dismissed from 504 services. If the student has not been dismissed, the current plan stays in effect.)
I AGREE that my child no longer has a disability that requires 504 services. I have received a copy of the RIGHTS AND PROCEDURAL SAFEGUARDS FOR SECTION 504. I understand these rights.
______
SIGNATURE(S) OF PARENT(S)/GUARDIAN(S)/SURROGATE/ADULT STUDENT
DATE: ______/ I DO NOT AGREE that my child no longer has a disability that requires 504 services. I have received a copy of the RIGHTS AND PROCEDURAL SAFEGUARDS FOR SECTION 504. I understand these rights.
I understand that without permission to implement this 504 Plan, the services will not be provided.
______
SIGNATURE(S) OF PARENT(S)/GUARDIAN(S)/SURROGATE/ADULT STUDENT
DATE: ______
Notice of 504 ELIGIBILITY/REVIEW MEETING
To: / From:Student’s Name: / Date Sent to Participants:
This meeting has been scheduled for: / Date: / Time: / Location:
THIS LETTER IS TO INFORM YOU THAT A MEETING HAS BEEN SCHEDULED FOR THE ABOVE NAMED STUDENT. THE PURPOSE OF THIS MEETING IS TO:
DETERMINE IF THE STUDENT CONTINUES TO BE ELIGIBLE FOR 504 SERVICES
REVIEW OF 504 ACCOMMODATION PLAN
Other:
The following are invited to attend and participate in the 504 meeting:
Principal/Designee / Occupational Therapist / Other Agencies (Transition, etc)
Regular Education Teacher / Physical Therapist / Other:
Special Education Teacher / Speech Therapist / Other:
Parent / Guidance Counselor / Other:
Student (If appropriate) / School Psychologist / Other:
If you have any questions or would like additional information or assistance to help you prepare for this 504 meeting, please contact
at / e-mail
Detach and Return the Section Below
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To the Parent/Student:
Student Name: / Date of 504 Meeting:Please check your choice and detach and return this section to / Fax # :
I, the parent, I, the student, will attend the 504 meeting as scheduled.
I, the parent, I, the student, cannot attend the 504 meeting as scheduled, however you may hold the meeting
in my absence.
Please reschedule the 504 meeting. / Suggested Dates:
Parent Signature / Date: / Date received by the school :
1st Attempt Date / 2nd Attempt Date / 3rd Attempt Date
CC: CUMMULATIVE FOLDER AND MCPS 504 COORDINATOR R01/19/12
DEPARTMENT OF EXCEPTIONAL PROGRAMS, 175 MAYFIELD DRIVE, P.O. BOX 190, BOYDTON, VA 23917
434.738.6111 434.447.7631 FAX: 434.738.0691