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Get WA Section 504 Referral and Recommendation

First M.I. Age _______ Parent/legal guardian ____________________________ Address Street City Program State Teacher(s) Zip Grade Telephone Home English proficient? Yes _____ Mother's work No _ Father's work Screened by ELL? Yes ___ No _____ Home language _____________________________________ Referral made by Position This referral and function of the Section 504 Team have been discussed with the parent/legal guardian Yes No Date Description of teacher/school/parent concern(s).

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