504 Accommodation Requests

If your child requires 504 Accommodations, please download and complete the forms below:

Note: ALL FORMS MUST BE FOR THE SCHOOL YEAR 2023-2024. Forms for 2022-2023 or prior years are not valid.

From Family: Fill out the AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

From Doctor: Have your child's health care provider fill out the MEDICAL ACCOMMODATIONS REQUEST FORM

Note that the former "Medical Review for 504 Accommodations" form is no longer needed

Please return both completed forms to Tessa Derfner, Assistant Principal, at TDerfner@schools.nyc.gov or to your child’s Guidance Counselor.

Requests for 504 Accommodations are reviewed by the NEST+m 504 Team monthly.

For more information on 504 Accommodations, and to find translated versions of these forms, please visit the Department of Education's 504 Accommodations webpage. Also see the Student & Family Guide.

NOTICE ON NON DISCRIMINATION UNDER SECTION 504

Section 504 of the Rehabilitation Act of 1973 is a federal law that requires public schools to provide accommodations to eligible students with disabilities to ensure these students are able to participate in DOE programs and activities on an equal basis with their peers who do not have disabilities. Please see the Notice of Non Discrimination Under Section 504 here.

Tessa Derfner
Assistant Principal
K-12 Special Education
TDerfner@schools.nyc.gov