Education Accommodation Plan Form
Provide comprehensive details to support and document an individualized education accommodation plan.
Student Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Primary Disability or Special Need (select all that apply)
*
Learning Disability
ADHD/ADD
Autism Spectrum Disorder
Physical Disability
Hearing Impairment
Visual Impairment
Speech/Language Impairment
Emotional/Behavioral Disorder
Other
Briefly describe the student's current academic strengths and challenges
*
Please rate the level of support needed in the following areas
*
Rows
No Support Needed
Some Support Needed
Significant Support Needed
Reading
1
2
3
Writing
4
5
6
Mathematics
7
8
9
Social Interaction
10
11
12
Attention/Focus
13
14
15
Organization/Planning
16
17
18
Requested Accommodations (select all that apply)
*
Extended time on tests/assignments
Preferential seating
Use of assistive technology
Modified assignments
Breaks during class
Alternative testing environment
Peer support
Other
Additional comments or information (optional)
Teacher/Case Manager Name
First Name
Last Name
Submit Accommodation Plan
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