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504 Appeal

Parent / Guardian must complete the information below and submit the form to appeal the findings of the 504 TEAM.

Student First Name: *

Student Last Name: *

Date of Birth: *

Grade: *

School *

Parent/Guardian Name: *

Phone Number: *

Email Address: *

Date of 504 TEAM Meeting: *

Type of Appeal: *

Disability Eligibility Accommodation

Summarize Reason for Appeal: *

By entering my name in this box, I acknowledge that the information above is true and accurate, and that this electronic signature has the same meaning as my handwritten signature.

Signature: *

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