Rice Lake Area School District

Pupil Services

4/11/14

REFERRAL FORM

504 Services

Initial / Reevaluation
Name of child(Last, first, middle) / Date of birth / Grade / School
Name of parent or legal guardian / Address (Street, city, state, zip)
Telephone area/no.
() / Person making referral/title / Date parent notified of intent to refer
Method of notifying parent of intent to refer
Conference Phone call Written / Is an interpreter needed? Yes No
Parent’s or adult student’s native language or other primary mode of communication if other than English (specify): Child’s native language or other primary mode of communication if other than English (specify):
Date of receipt of referral by building administrator
(month, day, year)
(Note: the date the district receives the referral begins the 15 business day timeline in which to complete the review of existing information and notify the parents of whether additional assessments are needed.)
1.  State reason you believe this student has a mental or physical impairment which substantially limits one or more major life activities. A major life activity includes but is not limited to functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing. At school “learning” is frequently identified as the area of difficulty. Common examples of physical or mental impairments include such things as communicable diseases (HIV, TB), medical conditions (Attention Deficit Disorder, asthma, allergies, diabetes, heart disease, seizure disorders, traumatic brain injury, etc.) and psychological disorders. Transitory conditions (those lasting six months or less) such as a broken ankle generally are not considered a disability. These conditions are considered on a case-by-case basis.
2.  List academic and non-academic performance and medical information; any special programs, services, interventions used to address this student’s needs and the results of those interventions, etc:

Principal

The Rice Lake Area School District does not discriminate on the basis of race, religion, color, national origin, sex, disability, or age in its programs and activities.

504 Referral Form

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