Rev August, 2004
LIVINGSTON PARISH PUBLIC SCHOOLS
13909 FLORIDA BLVD.
P.O. BOX 1130
LIVINGSTON, LOUISIANA 70754-1130
PHONE: (225) 686-7044 FAX: (225) 686-3052
Full and Effective Notice
Request for Informed Consent
Your child has been referred to the Section 504 Service Determination Committee for further evaluation
to determine eligibility for accommodations under Section 504 of the Rehabilitation Act of 1973.
The 504 SDC needs to evaluate your child in the following areas: _______________
(SBLC Referral Date)
____ Characteristics of ADHD
____ Academic Deficits in the Area of Mathematics
_____ Medical Condition: Specify medical condition:_________________
_____ Transfer: Your child’s records from have arrived and there is not
sufficient documentation of 504 eligibility.
Your signed consent is required to complete this initial evaluation. This assessment will be complete within 60 business
days unless an alternative timeline has been mutually agreed upon and documented. A copy of your Parental Rights under
Section 504 of the Rehabilitation Act of 1973 is enclosed.
Please check and return:
As a parent or guardian
_____I DO consent to this assessment
_____I DO NOT consent to this assessment (The Livingston Parish School Board has offered a 504 Initial
Evaluation to our child. However, at this time we do not wish to accept this evaluation. We have been advised of the
potential effect on our child’s education if services are not provided. It has been explained that we may decide to make a
request to SBLC to have our child’s needs addressed and the Livingston Parish School Board will continue to provide a
Free and Appropriate Public Education (FAPE) to my child to the extent possible without this evaluation.)
Parent/Guardian Signature:___________________________ Date:_______________
White – Parent Canary – 504 SDC