Bullhead City School District

1004 Hancock Road

Bullhead City, AZ 86442

Section 504
ADA Eligibility and Child Accommodation Plan

Child: A child

Date:

School: Elementary School

________________________________

DOB:

Review Date:__________________________________
Manager:

Case

Part 1: Justification for Services

Does the child have a physical or mental impairment that

substantially limits one or more of his/her major life activities?
[ x] Yes

[ ] No

Briefly document the basis for determining the disability:

Student is in remission for childhood cancer as described by her

pediatrician's doctor's note on file. Due to such, student requires specific
accommodations as outlined below to maintain health.

Describe areas of need and action to be taken:

Student has one kidney with limited function and needs to remain hydrated.

Area of difficulty: Multiple surgeries resulting in one kidney

Accommodation: Frequent bathroom use as requested by student; unable to
"hold it"

Area of difficulty: Limited kidney function

Accommodation: Regular and frequent access to water to maintain hydration
and overall kidney health

Section 504 Committee

Title

Ms.

Mother

Ms.

Classroom Teacher

Ms.

Assistant Principal

Mr.

Principal

Date

I have reviewed this accommodation plan and agree with its implementation

______________________________________________________________
_________________
Parent Signature

Date to review plan:______________________________________________

Date