PARENT
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TANGIPAHOA PARISH SCHOOL SYSTEM
SCREENING/ASSESSMENT CONSENT FORM
Dear Parent/Guardian:
Tangipahoa Parish School System, in compliance with Bulletin 1903 [R. S. 17:7 (11)
(B)], will provide an initial screening for every child in grades k – 3, at least once, for
dyslexia and related disorders, ADHD, and social and emotional “at risk” factors. In order
to fulfill its obligation under Section 504, the school system recognizes a responsibility
to avoid discrimination in policies and practices regarding its students.
Signed consent will allow screening, and assessment if needed, at school, for the entire
period a student is enrolled in any public school in the Tangipahoa Parish School
System. Consent may be rescinded in writing at any time. Please return this form to the
homeroom teacher.
I understand that if this consent is not signed, the student named below will not be
screened.
Student:____________________________Date:____________________
Parent/Guardian Signature:____________________________________
YES _____
Tangipahoa Parish School System has my permission to provide an
initial screening for dyslexia and related disorders, ADHD, and social
and emotional “at risk” factors.
NO _____
Tangipahoa Parish School System does not have my
permission to provide an initial screening for dyslexia
and related disorders, ADHD, and social emotional “at risk” factors.
“The Tangipahoa Parish School System does not discriminate on the basis of race, color, national origin, sex,
age, disabilities or veteran status. We are an equal opportunity employer.”
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Tangipahoa Parish School System
Parent/Student Rights in Identification, Evaluation and Placement
Section 504 of the Rehabilitation Act of 1973
The following is a description of the rights granted by federal law to students with disabilities. The intent of the law is to keep you fully
informed concerning decisions about your child and to inform you of your rights if you disagree with any of these decisions.
You have the right to:

Have your child take part in and receive benefits from public education programs without discrimination because of
his/her disabling condition;

Have the school district advise you of your rights under federal law;

Receive notice with respect to identification, evaluation, or placement of your child;

Have your child receive a free appropriate public education. This includes the right to be educated with non-disabled
students to the maximum extent appropriate to the needs of the disabled student. It also includes the right to have the
school system make reasonable accommodations to allow your child an equal opportunity to participate in school and
school-related activities;

Have your child educated in facilities and receive services comparable to those provided non-disabled students;

Have your child receive specially designed education and related services if she is found to be eligible under the
Individuals with Disabilities Education Act;

Have transportation provided to and from an alternative placement setting at no greater cost to you than would be
incurred if the student were placed in a program operated by the district;

Have the interpretation evaluation data and placement decisions based upon a variety of information sources and
placement decisions made by persons who know the student, the meaning of the evaluation data, and placement
options;

Have your child provided with an equal opportunity to participate in nonacademic and extracurricular activities offered
by the system;

Examine all relevant records relating to decisions regarding your child’s identification, evaluation, education program,
and placement;

Obtain copies of educational records at a reasonable cost unless the fee would effectively deny you access to the
records;

A response from the school system to reasonable requests for explanations and interpretations of your child’s records;

Request amendment of your child’s educational records if there is reasonable cause to believe that they are inaccurate,
misleading, or otherwise in violation of the privacy rights of your child. If the school system refuses this request for
amendment, it shall notify you within a reasonable time and advise you of the right to a hearing;

Request and participate in a review or an impartial hearing, with counsel if desired, related to decisions or actions
regarding your child’s identification, evaluation, educational program or placement;

Request payment of reasonable attorney fees if you are successful on your claim;

File a local grievance with the Section 504 Coordinator to resolve complaints of discrimination other than those involving
the identification, evaluation, educational program or placement;

File a complaint with the Office of Civil Rights.
The person at the school who is responsible for Section 504/ADA compliance is the building principal.
The District Section 504 Coordinator may be contacted at the TPSS Central Office, 59656 Puleston
Road, Amite, LA 70422, (985) 748-2477.
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Tangipahoa Parish School System
Section 504 Parent Notification/Oral Interpretation
Student: ______________________SS/ID#:__________________Date:______________
School: ________________________Grade:_______Teacher:______________________
Dear: _____________________________
The Section 504 committee has scheduled a meeting concerning your child for the reason(s) indicated
below.
______Section 504 Evaluation/Re-evaluation and Oral Interpretation
______Section 504 Individual Accommodation Plan and Oral Interpretation
______Act 1120 Screening/Assessment Oral Interpretation
______Section 504 Manifestation Determination Relatedness Hearing
______Section 504 Student Accommodation Refusal
Your attendance at this meeting will be greatly appreciated.
DATE:
_________________________
TIME:
_________________________
PLACE:
_________________________
Sincerely,
______________________________
Section 504 Chairperson
______Parent did not attend meeting and a copy was mailed on ____________________.
OR
______The Section 504 Evaluation/Re-evaluation and/or Individual Accommodation Plan and/or the
Act 1120 Screening for my child has been explained to me. I understand the oral explanation and the
written plan has been provided to me. I retained a copy of the plan.
__________________________
Parent/Guardian Signature
_________________________
Date
_________________________
Section 504 Chairperson
_________________________
Date
______Parent/Student Rights Attached
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Tangipahoa Parish School System
Section 504 Student Accommodation Refusal
Student’s Name:_________________________Date:____________Grade:________
School:__________________________________I. D. #:________________________
Teacher:__________________________Principal:____________________________
The student and parent must sign this form if student chooses not to accept accommodations
as specified on the Section 504 - Individual Accommodation Plan and Test Verification Form.
Student
I understand that my parent/guardian will be notified and must approve of my decision by
signing this form. I select not to accept class and test accommodations as recommended by
the Section 504/Student Assistance Team.
I, _________________________________________, will not accept the
(student’s signature)
accommodations as specified on my Individual Accommodation Plan.
_________________________
(date)
Parent/Guardian
The parent/guardian must sign acknowledging and approving the student’s decision.
I am the parent/guardian of ___________________________________.
(student’s name)
I approve of the student’s decision not to accept accommodations as
specified on his/her Section 504 Individual Accommodation Plan. I reserve
the right to request a Section 504 Reassessment.
____________________________
(parent/guardian signature)
______________________
(date)
Signature of Witnesses:
__________________________
Principal or Assistant Principal
_______
Date
_____________________
Section 504 Chairperson
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_______
Date
TANGIPAHOA PARISH SCHOOL SYSTEM
Section 504 Parent/Guardian Notification of Ineligibility
______________________________
(date)
TO:
Parent:
___________________________________________________
Address: __________________________________________________
(street / p. o. box)
___________________________________________________________________
(city)
FROM:
(state)
(zip)
Section 504 Chairperson: ______________________________________
Principal: __________________________________________________
School: ____________________________________________________
SUBJECT:
Section 504 Ineligibility
You were invited to a meeting on ___________________________________________. Courtesy
has been extended and a copy of the reassessment is attached. Your child,
__________________________________, has been reassessed and eligibility for 504
accommodations has ended. An annual review is no longer needed. The student may
be reconsidered for eligibility at any time through the Student Assistance Team process.
“The Tangipahoa Parish School System does not discriminate on the basis of race, color, national
origin, sex, age, disabilities or veteran status. We are an equal opportunity employer.”
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