The School Board of St. Lucie County, Florida Notice/Consent for Evaluation Under Section 504 To the Parent(s) of or Adult Student: Student ID# School: Date of Birth: Grade: We have carefully reviewed your child’s school record and information from teachers. Additional information is necessary to fully determine your child’s educational needs and whether he/she might be eligible for assistance in the general educational setting under Section 504. We are requesting that you consent to an evaluation under Section 504 that may include, but not be limited to, to the following assessments. Academic and/or Pre‐academic Speech and/or Language Purpose: To assess current academic skills or pre‐readiness skills. Purpose: To assess communication skills, language ability, articulation skills, fluency and voice quality. Hearing Purpose: To screen a student’s hearing ability. Vision Purpose: To screen a student’s visual ability. Psychological Process Assessment Cognitive Functioning Purpose: To assess auditory, visual motor and language functioning Using psychological process assessment tools. Purpose: To assess how tell a student remembers what (s)he has Seen and heard, how well (s)he uses information and how (s)he Solves problems. The tests also reflect learning rate and assist in predicting how well (s)he may do in school. Social/Adaptive Functioning Behavioral/Emotional Functioning Purpose: To assess social and adaptive ability. Purpose: To assess the student’s behavioral and/or emotional Interactions. Functional Behavior Assessment Purpose: To identify functions of behavior ______________________________ ______________________________ Other (Specify As needed) ____________________________________________________
Parent/Guardian/Student 18 years or older, must complete the following: One of these MUST be checked:  I consent to an evaluation under Section  I do not consent to an evaluation under 504 and I have received a copy of the Section 504 and I have received a copy Parent/Student rights. of the Parent/Student rights. Signature: Date: Home Phone: Work/Cell: You have specific rights concerning the proposed Section 504 evaluation. The rights are explained in the attached parent/student rights. For a further explanation of these rights, contact the school counselor or Section 504 designee. I have received a copy of the Parent/Student rights: Initials________ Date _______________ If the native language of the parent/adult student is other than English, a translator was provided.  Yes  No Original: Cumulative file Copy to Parent/Adult Student Copy to Student Services STS0132 Rev. 7/10