El Segundo Unified School District

Section 504
Determination of Eligibility
[X] Initial Evaluation [] Review/Update [] Review/No Changes

Student Name: Miles Christian Birth Date: 06/27/2003 Date: 10/27/20

School: El Segundo High School Grade: 12 Home Phone: 310-428-4159
Parent/Guardian Name: Danielle and Mark Christian Work Phone: 310-428-4159 (mom’s cell)
Address: 1305 E. Grand Ave. Unit A, El Segundo CA 90245

School Contact Person: Ms. Burns Title: Counselor Phone #:

Reason for Referral/Area of Concern:

504 Review

Review of Information – Variety of sources of evaluation information:

Parent Information
Miles has been diagnosed ADHD, depression, anxiety, and bipolar disorder. Doctor’s believe he is on the spectrum, but he
has not been tested yet. Ms. Van Horn has sent home assessment paperwork.

Teacher Information (attach student work samples reviewed):

Teachers report that Miles is engaged and participates but does not turn in work consistently.

Academic, Adaptive Behavior and Cognitive Assessment Information:

Current grades: Jazz Band: F (22%), Advanced Band: F (15%), English 12: N/A, Econ: D (66%), AP Calc: D (64%), AP
Psych: B (84%)

Behavioral Information:
Parents were unaware that Miles was off his medication for a few weeks after school started. He has been back
on his medication for about a week and half.

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 Student Name: Miles Christian Date: 10/27/202

Health/Medical Information (attach medical reports reviewed):

Lamictal, 100 mg. (daily) and Seroquel, 200 mg. (daily)

Summary of Findings:
To qualify, the top two (2) Yes/No choices must be checked YES and one or more marked 4 or 5 or choice 3 or 4 must be
checked YES

[X] Yes [] No Does the student have a physical or mental impairment? If so, check the impairment:
Section 504 regulations define a “physical or mental impairment” as any physiological disorder or condition,
cosmetic disfigurement or anatomical loss affecting one or more of the following body systems:
[] Neurological [] Musculoskeletal [] Special sense organs
[] Respiratory [] Speech organs [] Cardiovascular
[] Reproductive [] Digestive [] Genito-urinary
[] Hemic and lymphatic [] Skin [] Endocrine
[X] Other: ADHD, bipolar disorder, and depression/anxiety

Any mental or psychological impairment such as:

[] Mental retardation [] Organic brain syndrome [] Emotional or Mental illness
[] Specific learning disabilities [] Other:

[X] Yes [] No Does the physical or mental impairment affect one or more major life activities such as:
[2] Caring for one’s self [1] Performing manual tasks [1] Walking
[2] Seeing [2] Hearing [2] Speaking
[1] Breathing [2 ] Learning [5] Working
[3] Eating [3] Sleeping [1] Standing
[1] Lifting [3] Reading [5] Concentrating
[4] Thinking [4] Communicating [4] Other: Maintaining Social Relations

Place a number based on the following scale to indicate the specific degree that the impairment(s) limits the major life
activity(ies). For 4.0 or above, fill in specific information evaluated by the team that justifies the rating. To be eligible under
Section 504, a student must have a physical or mental impairment that substantially limits a major life activity, a record of
such an impairment, or being regarded as having such an impairment.

5 = Extremely 4 = Substantially 3 = Moderately 2 = Mildly 1 = Negligibly

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[] Yes [X] No Does the student have a drug addiction that substantially limits one or more of the student’s major life
activities and the student is participating in a drug rehabilitation program. If yes, the student does meet the
definition of a person eligible for Section 504 services.

[] Yes [X] No Is the student significantly impaired in a life activity because of the use of alcohol? If yes, the student is
eligible for Section 504 services but is subject to the same disciplinary action as student without disabilities.

Mitigating Measures:
Describe devices or practices the student currently uses to correct or reduce the effects of their impairment (i.e. medication,
prosthetics, mobility devices, assistive technology, low-vision devices, oxygen supplies and equipment, hearing devices, etc.)

Lamictal, 100 mg. (daily) and Seroquel, 200 mg. (daily)

Trying to eat food and beverages that naturally treat ADHD

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Student Name: Miles Christian Date: 10/27/20

Health/Safety Considerations:
Describe any situation related to the student’s impairment that may need caution, restriction, or medical intervention:

N/A

Eligibility Determination:
Based on a review of relevant student information, the Section 504 Team has determined:

[] The student is eligible under Section 504 and will receive an Accommodation Plan.
[X] The student remains eligible under Section 504 and will receive an updated Accommodation Plan.
[] The student is no longer eligible for Section 504 and is exited from the program. The student will now receive regular
education without Section 504 services.

[] The student is not eligible for services under Section 504 and will continue to receive regular education and any available
regular education resources and programs.

Parent Consent – Placement / Services

[ ] Yes, I consent to placement and services for my child as listed in the attached 504 Plan.
[ ] No, I do not consent to placement and services for my child as listed in the attached 504 Plan

________________________________________ ________________________________________ ____________________

Print Parent/Guardian Name Parent/Guardian Signature Date

Names of Persons in Attendance:

Name: ______________________________________________ Title: Student

Name: ______________________________________________ Title: Counselor

Name: ______________________________________________ Title: Intervention Specialist

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 El Segundo Unified School District
Section 504
Accommodation Plan
[X] Initial Evaluation [] Review/Update [ ] Review/No Changes

Student Name: Miles Christian Date: 10/27/2020

School: El Segundo High School Grade: 12 Birth Date:
Date Plan Initiated:

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

 flexible time and flexible
test setting (alternate
assessments when
necessary)
ADHD and Anxiety Student/Teacher
 when possible, Miles will
be allowed to come to
campus for assessments
 asynchronous learning
 bi-weekly (twice a month)
check-ins with Intervention
Student/Interv.
Depression Specialist
Spec./Teacher
 frequent check-ins with
teachers

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Participation in state and district-wide assessment: [] No accommodations [X] Accommodations as stated above

Additional Accommodations/Comments:

Notes:

Currently Miles has 195 credits. He needs 210 (minimum) to graduate. He must pass English (10 credits), Econ (5 credits), and
Polit. Behavior (5 credits)

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