Requirements for 504 Plan

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Today's Date: xx/xx/xxxx Section 504 for Brooklynn Grade: 6th Birth Date: xx/xx/xxxx EMERGENCY CONTACT PHONE NUMBERS: (Mother) (Father) (Pharmacy) * (Hospital) (Pediatrition) Summary of Concerns and Past Interventions: Brooklynn is a general education student who has type 1 diabetes, which may interfere with normal school activities and requirements. Section 504 applies to Brooklynn because of the following: Type 1 Diabetes, as diagnosed by a physician, is a physiological disorder that affects the endocrine system. Type 1 Diabetes places the individual at risk for hypoglycemic and hyperglycemic episodes related to metabolic dysfunction. Potential fluctuations in blood glucose impact the individual’s major life activities in the area of learning, which is one of the specific major life activities described in Section 504. Both high blood sugar levels and low blood sugar levels affect Brooklynn's ability to learn and perform in school, as well as seriously endangering her health. Blood glucose levels must be maintained in the 80-150 range for optimal learning and testing of academic skills. Brooklynn has a recognized disability, Type 1 Diabetes, that requires the accommodations and modifications set out in this plan to ensure that she has the same opportunities and conditions for learning and academic testing as classmates, with minimal disruption of her regular school schedule and with minimal time away from the classroom. Steps to prevent hypoglycemia and hyperglycemia, and to treat these conditions if they occur must be taken in accordance with this Plan. Accommodations that are necessary for Brooklynn: 1. Brooklynn shall be permitted to use the bathroom without restriction. 2. Brooklynn shall be permitted to have immediate access to water, including keeping a water bottle in her possession and being allowed to
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