Sample Letter – Section 504 Determination Request

Sample Letter - 504 Determination Request - aspire pans pandas

  • Keep a copy for yourself.
  • Hand deliver and ask for a date stamp or send with Return Receipt to establish timeline or email as an attachment.

(Parent/Guardian Name)
(Home Address)
(City, State, Zip Code)
(Daytime Telephone Number / Email)



(Administrator Name)
(Title – i.e. Director of Student Services / District 504 Coordinator)
(School District)
(District Office or School Address)
(City, State, Zip)

Regarding: Section 504 Determination

Student Name: ( )
Date of Birth: ( )
Name of School: ( )
Grade: ( )

Dear (Title – i.e., Dear District 504 Coordinator and School Principal),

My child, (child’s name), is a student in the (number) grade in (Teacher’s Name’s (or leave out if in high school or put in guidance counselor)) class at (name of school). I am writing because (give a brief explanation with relevant facts like diagnosis/es and history to support your concerns.)

(For example) My child was diagnosed with PANS PANDAS two years ago. Classroom modifications were made during her first flare, but her disorder has increasingly worsened, and is now struggling to access the curriculum. PANS PANDAS impacts [shis/her] educational performance and would benefit from accommodations and supports. She has difficulty writing legibly due to her dysgraphia.  Her OCD and anxiety are impacting her ability to (x, y, z). So, when she gets home, she is emotionally and physically exhausted and unable to complete her unfinished school assignments or start her homework. In addition, she is having executive functioning issues and would benefit from having a few supports around this PANS symptom.

To address this situation, I am requesting that (student name) receive appropriate supports to help her learn pursuant to Section 504 of the Rehabilitation Act.

(Optional: You can expand on what you would like to happen.)

(Optional: You can discuss strategies that have already been tried but have not been effective while focusing on what you want.)

(Optional: Provide information from providers with this initial letter or let the school know you have them.) (For example) We have documentation about my child’s PANS PANDAS from her provider/s. (list independent evaluations, or doctor or therapist letters/reports) to be used as part of the materials to determine eligibility for a 504 plan. Attached please find a letter regarding her diagnosis and need for a 504 plan.

(Wrap up with how you would like to be notified of the next steps and the timeline.) (For example) I want the school to set up a brief meeting within the next week to discuss the timeline for assessing her for a 504 plan. Additionally, I would like to set up the 504 meeting date. Please respond by (phone call, email, return letter). I look forward to hearing from you and working as a team to put an appropriate plan in place to help (child’s name) learn and succeed. 

Thank you for your attention to this matter.





(Parent/Guardian Name)

cc: (your child’s teacher) and (other staff if applicable)


Sample Letters

Learn more about PANS PANDAS in the school setting. PANS PANDAS is a medical condition in which symptoms affect a student’s ability to attend school and learn.


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