Parent Input Sheet
1. What do you feel is your child’s disabling condition that necessitates that he or she have a 504 plan?
2. How does it impact his or her daily life activities?
3. How does it impact his or her educational program?
4. What necessary accommodations do you believe your child needs in order to be successful in school?
Sample 504 Plan for Caudal Regression Syndrome
Date of Agreement:
Reason for Service
Student is transitioning into a school-aged program from preschool. His primary disability is Orthopedic Impairment. He has a medical diagnosis of caudal regression syndrome/sacral agenesis, which has affected his pelvis, legs, bladder and bowel function. In addition, Student has a hearing loss in his right ear. He cannot sit pretzel style and uses a cushion when sitting. Student ambulates with a rolling walker or crutches.
Student’s kidneys are low in the front of his body, not up in the back like in most people. Therefore, his kidneys are unprotected by his ribs and could be damaged if he has a blow to the abdomen. He plays normally with other kids but must avoid contact sports (being too rough, tackling, etc.).
Student also has some fused vertebrae in his neck, so it is like he doesn’t have some of the “padding” between the bones in his neck. He should not do any activities that will put stress on his neck, such as “heading” a ball or doing somersaults.
Because the nerves to Student’s bowel and bladder do not function reliably, he is not fully potty trained yet, and the urologist does not foresee continence for Student without surgical intervention (which would take place when Student is around 8 to 10 years old).
Because of his neural tube disorder and frequent surgeries, Student has a high risk of developing an allergy to latex and natural rubber and must avoid being in the same room with latex gloves, Band-Aids, balls, balloons, erasers, and so on.
- Bathroom breaks: Student will have regular bathroom breaks spaced at preset intervals with times to be determined (especially after eating and after physical activity).
- He will go to the nurse’s room for assistance.
- He will have extra changes of clothes and Pull-Ups kept at school at all times kept in the nurse’s office.
- Student will be allowed to take extra bathroom breaks as needed.
- Student will not be exposed to or near latex, including gloves, Band-Aids, balls , balloons, erasers, and so on.
All adults working with Student will be notified of his latex sensitivity.
Parent and School Nurse will meet once the building Master Schedule has been determined to best support Student at the beginning of the school year, for his medical services.
Recommendations: Proposed Physical Therapy for Student is 90 minutes/week. Services will be a combination of push-in and pull-out with ongoing consultation between classroom teacher and staff. Fall reassessment will occur for PT services to be adjusted for the 2009-2010 school setting. The preschool school transition evaluation is attached.
- Use of a walker or forearm crutches to ambulate the school environment
- Seat cushion provided by parents
- Seat cushion when attending performances, assemblies or prolonged periods of time (student chair when needed)
- Ongoing written communication between parents and teacher
- Preferential seating for hearing – teacher to face Student’s left side when speaking to him or delivering instructions
- Wheelchair provided by parents for field trips as needed
- Parents will provide written permission for Student to be lifted on and off a bus for any District provided transportation
- Avoid Contact Sports and any activities that put stress on his neck ex. “heading” balls and doing somersaults.
Transportation: Parents will provide transportation to and from school.
Note: Student’s full Preschool evaluation, Physical Therapy evaluation, Parent Input document, and article on Caudal Regression Syndrome are attached to this document.
Please indicate agreement to the above plan by signing the appropriate line below.
Parent(s) signature Date
Parent (s) signature Date
Principal’s signature Date
Additional Info on 504 Plans
Here are some helpful links on 504 Plans:
What is a 504 Plan
The Parental Advocate
Section 504 Information
Accommodations for Kids with Mobility Impairments
We debated with them back and forth about putting something about classroom accessibility into the plan. However, they kept coming back to their point that the classroom has to be accessible for ALL students, not just our son, so it's not an accommodation. When researching this, I did find some good links on universal design, though, which may be helpful if you do want to insist on something about classroom accessibility in the plan. These links include:
Applications of Universal Design
ADA Accessibility Guidelines
A Checklist for Designing Spaces That Are Welcoming, Accessible, and Usable
The Accessible Classroom