504 form

From Afehandbook

SAMPLE: 504 FORM FOR STUDENTS WITH ANY TYPE OF DISABILITY (note accommodations are determined by needs of disability so this list does not include all possible accommodations)

AFE Student Name Here (STUDENT Z)

Section 504 Service Plan

Date Written here:

Summary of Assessment

Summary of Assessment: Please refer to 10/7/2006 Spec. Ed Assessment report and letter from physician. STUDENT Z has diagnosis of dyslexia, dysgraphia, and processing issues.

Long Term Educational Goals:

Long term goal: Successful completion of classes in 8th grade and junior high school diploma

Educational objective: Successful academic participation in classes

Modifications and Accommodations

School responsibility:

- Supply "Books on Tape" for academic subjects, - allow use of keyboard for all written work, - reduced amount of written assignments, - extra time allowed for processing, testing, and any handwritten tasks. - Allow student to demonstrate knowledge through verbal report or other media (artwork, video, models, etc.)

Student responsibility

- Student will request accommodations when needed. - student will meet with teacher once per month

Parent responsibility

- Parent will support student in requesting accommodations and communicate with staff if needs are not being met.

Communication schedule: Once per month