504 Plan Request Letter (Fillable Template)

(Your address)

(Date)

(Principal's name)
(School name)
(School address)

Re: Request for Section 504 Evaluation — (Student's full name), DOB: , Grade:

Dear ,

I am writing to formally request an evaluation for my child, , under Section 504 of the Rehabilitation Act of 1973, to determine eligibility for a 504 plan.

My child has been diagnosed with the following condition(s): . These condition(s) substantially limit one or more major life activities, including but not limited to: (e.g., learning, reading, concentrating, thinking, communicating, walking, breathing).

Because of these limitations, my child is experiencing the following difficulties at school: .

I am requesting that the school:

1. Provide me with written notice of my procedural safeguards under Section 504;
2. Convene the 504 team to evaluate my child promptly; and
3. Develop a 504 plan with appropriate accommodations if my child is found eligible.

Accommodations I would like the team to consider include: (e.g., extra time on tests, attendance flexibility for medical appointments, permission to leave class for medical needs, reduced-distraction testing environment).

Please respond to this request in writing within a reasonable time. I can be reached at (phone) or (email).

Thank you for your attention to this matter.

Sincerely,

(Parent/Guardian signature)

(Printed name)    Date: