An Administrator's Guide to California Private School Law Compendium

D OCUMENT 9.K

R EQUEST F OR D OCTOR T O P ROVIDE E XAMINATION F OR S TUDENT The student named below may be eligible for services and accommodations offered by [school] pursuant to the Americans with Disabilities Act. In order to determine eligibility, we request your assistance in providing us with information so that we can determine whether we can provide the student with reasonable accommodations in the academic environment. TO BE COMPLETED BY PARENT/GUARDIAN Student’s Last Name: __________________ Student’s First Name:________________ Date of Birth: __________________ I authorize the release of information requested below to [school]. Parent’s/Guardian’s Signature: __________________ Date: __________________ TO BE COMPLETED BY LICENSED PROFESSIONAL The School requests you to examine whether [student] is disabled and needs reasonable accommodations. To that end, please respond only to the following questions. The School seeks information regarding whether [student] has a disability, what [his/her] functional limitations are as a result of that disability, and whether [he/she] needs accommodations. 1. Does [student] have a mental impairment or physical impairment that substantially limits [his/her] ability to engage in a major life activity, such as the ability to attend school, care for [himself/herself], perform manual tasks, breathe, see, hear, speak, learn, concentrate, walk, sit, stand, or participate in school activities? 2. If the answer to question number one is yes, does the impairment currently affect [student’s] ability to participate in the School’s academic environment? If so, please indicate what the student’s functional limitations are with regards to [his/her] ability to participate in the School’s academic environment. 3. If the answer to question number two is yes, is there an accommodation(s) that can be made that would enable [student] to participate in the School’s academic environment? Please identify the accommodation(s).

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