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Balderas - Section 504 Internal Referral Form
Complete this form if you are aware of a student that may have a physical or mental impairment that substantially limits a major life activity.
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Email
*
Your email
Your Name
*
Your answer
Your Role
*
Teacher
Administrator
Counselor
Nurse
Other staff member
Parent
Other:
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student ID#
Your answer
Please describe the student's suspected physical or mental impairment.
*
Your answer
Does this student have a medical diagnosis? *This question is for informational purposes only, as a medical diagnosis is not required to be eligible under Section 504.
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Yes
No
Other:
What major life activities are substantially limited due to the suspected physical or mental impairment?
*
Your answer
Please provide any other information that would be beneficial to the §504 Campus Coordinator.
Your answer
A copy of your responses will be emailed to the address you provided.
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