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Here is a sample 504 Plan. 

SCHOOL NAME

Accommodation Plan

Section 504 of the Rehabilitation Act of 1973

Student:                                               School Year:   2019-2020

Conference Date: 

Grade: 

Teacher: 

Parents:  

Address:

Phone:   

Is there a documented physical or mental impairment, which substantially limits a major life activity?

              Yes    <!–[if supportFields]> FORMCHECKBOX <![endif]–>