Sample Request for a 504 Plan letter

Your name

Your Address

City, State, Zip Code



_______________(Teachers or Administrators)

School /School district


City, State, Zip Code


Dear ____________________

My name is/we are _______________________________ I/we am/are the parent(s) of ____________________ who is in the _____grade at ______________________ (Name of school). (Student’s name) has recently been diagnosed with (List of diagnosis), that impact directly his/her access to education and performance. The teachers have provided some assistance in areas of concern; however (student’s name) continues to have difficulties, as some of the interventions have been unsuccessful.

In order to address my/our concerns I/we are requesting that (student’s name) be considered for a 504 plan in accordance to Section 504 of the Rehabilitation Act of 1973.

I/we understand that I/we will be receiving the paperwork I/we must sign and return to give consent for the evaluations before the evaluations may be performed.

I/we look forward to hearing from you and working with you and your staff.




Cc: – People who you want to send this letter too.

Save a copy for your home file.

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