504 Plan Template

504 Plan Template
Please put the school information in this section like address, contact number, email address, and website URL.
Student Information
Name
First NameLast Name
Student Number
Date of Birth
MonthDayYear
Date
Age
Gender
Grade Level
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Parent/Guardian Name
First NameLast Name
Relationship
Other
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Disability/Disabilities
Is it a mental impairment?
Other
Is it a physical impairment?
Other
Does the child/student have any allergies? If yes, please list them below
Was the child/student previously hospitalized? If yes, please explain in detail below the reason and when.
Did the child/student previously undergo any surgery? If yes, please indicate the reason, the date, and the name of the procedure.
Eligibility
Effectivity Start Date
MonthDayYear
Date
Effectivity End Date
MonthDayYear
Date
Facilitator Information
Teacher/School Adviser
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Facilitator (504 plan coordinator):
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Support Plans and Goals
Initial Evaluation Comments
Describe the areas of needs and plan of actions
Daily Activities
Goal Setting
Rows Goal Description Met Not Met Remarks
1 1 2
2 3 4
3 5 6
4 7 8
5 9 10
6 11 12
7 13 14
Accommodations required to achieve the needs of the child/student
Signatures
Parent/Guardian Name
First NameLast Name
Parent/Guardian Signature
Title
Date Signed
MonthDayYear
Date
504 Coordinator Name
First NameLast Name
504 Coordinator Signature
Title
Date Signed
MonthDayYear
Date
Administrator Name
First NameLast Name
Administrator Signature
Title
Date Signed
MonthDayYear
Date
Teacher Name
First NameLast Name
Teacher Signature
Title
Date Signed
MonthDayYear
Date
Should be Empty:

Rows	Goal Description	Met	Not Met	Remarks
1		1	2
2		3	4
3		5	6
4		7	8
5		9	10
6		11	12
7		13	14