Riverside Middle School Section 504 of the Americans with Disabilities Act Consent Form

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Your child has been referred to determine eligibility for accommodations under Section 504 of the Rehabilitation Act of 1973.

The following information will be reviewed to facilitate determination of eligibility under Section 504:

Physicians Certification/Diagnosis
Academic records
State testing/Assessment data
Teacher comments/interviews
Behavior/Conduct
Attendance
Current 504 plan if applicable
Past 504 accommodations if applicable
Additional information as needed

Your informed written consent is required in order to proceed with the referral and possible assessments. All findings will be reported, recorded, filed and communicated in strict accordance with applicable district policies and state and federal law. A copy of your Parent Rights under Section 504 of the Rehabilitation Act of 1973 will be provided to you.

Email *

Student's First Name: *

Student's Last Name: *

Student's Grade: *

As parent(s)/guardian(s), I/We DO/DO NOT consent to these referral proceedings and/or assessments. I/We understand that my/our consent may be revoked at any time prior to the completion of this assessment *

CONSENT

DO NOT CONSENT

Type your FULL name below as your acknowledgement and electronic signature. *

A copy of your responses will be emailed to the address you provided.

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