NCCA 504 Referral Form 

Any person who believes a student has a disability that substantially limits one or more major life activities may refer a student for consideration of a Section 504 evaluation.  Complete this form and send any information available regarding a diagnosis or evaluation pertaining to the impairment or suspected impairment. (i.e., medical reports, psychological reports, etc.) to the 504 Coordinator.

NCCA District 504 Coordinator: Maggie Bush

Email: mbush@myncca.com

Phone number: (984) 208 - 7125


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Email *
Date of 504 Request *
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Student Name *
Student Date of Birth *
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Student Grade *
Person filling out form and relationship to student *
Reason for referral (be specific)
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Mental or physical impairment or suspected impairment
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Major life activities impacted (examples: hearing, seeing, communication, learning, taking care of oneself, walking, speaking, breathing)


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Describe impact of impairment on the major life activities listed
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Has the student ever been eligible for special education services? If the answer is yes, when was the student exited from services?
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Are you aware of any mitigating measures (e.g. medication, hearing aids, etc.) that impact the student educationally?  If yes, please describe the impact of the mitigating measures.

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Does the student currently have a health plan?
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Does the student require adaptive equipment or facility adaptation?
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What type of efforts have been attempted to meet the student’s needs (interventions, accommodations, etc)? How effective have these efforts been?
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Do you have anything else you would like to add that would help us better understand the student?

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