Sample 504 Plan Page 1 of 2

There is no standard 504 plan for schools to use. This form shows you an example of what could be included in a 504 plan.
A 504 plan should be tailored to your child’s needs.

Keep in mind the school is allowed to use its own form or not use a written 504 plan at all. In these cases, you can still use
this sample plan to take notes and organize your thoughts.

School Name:

Student Name: Date of Birth: Grade:

Qualifying Disability: Date Plan Written:

Date Plan Goes Into Effect: Date Plan to Be Reviewed:

Documentation of Disability (see attached):

504 Team Members Title Contact Information

Administrator

General education teacher

Related service provider

Parent

Other:

Other:

TEACHER EDUCATION AND SUPPORT

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Sample 504 Plan Page 2 of 2

ACCOMMODATIONS AND/OR SERVICES

Area of Educational Need Accommodation Person(s) Responsible Frequency of

or Service for Implementing Accommodation or Service

NOTES

Date Approved: