504 Student Eligibility

							                                                                                        Camas School District
                                                                                 Section 504 Student Eligibility

                                                                           Referral Date:


Student Last Name:                                   First:                           Middle:
Gender:      Female        Male       DOB:                          Age:               Grade:


Describe the nature of the concern(s):
What is the mental or physical disability?
Describe the basis for the determination of disability if any (screening and evaluation data):

Describe how the disability impacts learning and/or access to other educational benefits or services:

Is the student eligible under Section 504?     Yes       No
        If yes, describe recommended accommodations/services:

        If no, describe team recommendations:


504 Team Members
Name:                                                             Title:

Name:                                                             Title:

Name:                                                             Title:




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