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 2021-2022. Forms for 2020-2021 are not valid.

From Family: Fill out the authorization-for-release-of-health-information-pursuant-to-hipaa-school-year-2021-2022.pdf

From Doctor: Have your child's health care provider fill out the medical-accommodations-request-form-school-year-2021-2022.pdf

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 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.

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