• Special ed, 504 forms and samples

From Afehandbook

504 Form 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: 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