PM-ACE-R-7

ACTON SCHOOL DEPARTMENT
SIGNATURE OF RESPONSIBILITY

My signature below indicates that I have received a copy of _________________________________________________’s 504 Plan. I understand that it is my responsibility to implement the 504 Plan as outlined wherever I am the responsible party, which includes all classroom accommodations. I am also aware that I can call a team meeting at any time. This release is to be maintained in the student’s cumulative file as part of his/her educational record. Removal of this form from the student’s file constitutes a violation of student record maintenance requirements and may be punishable under the law (FERPA, IDEA, Section 504, and State) or any other law(s) governing the destruction of student records without parental notification.

Teacher’s Name: Teacher’s Signature Date

______________________________________ ______________________________________________ ______________________________

While 504 Coordinator, I am responsible for ensuring these teachers will receive any amendments to this student’s plan.

504 Coordinator:___________________________________________________________________ Date:________________________

Adopted: December 13, 2016

Reviewed: September 8, 2025

ACE-R-7

Safe - Responsible - Respectful

700 Milton Mills Rd
Acton, ME 04001
PH: 207.636.2100
FAX: 207.636.3045

We are committed to providing a website that is accessible to the widest possible audience, regardless of technology or ability. This website endeavors to comply with best practices and standards defined by Section 508 of the U.S. Rehabilitation Act.

ACE-R-7

Safe - Responsible - Respectful

700 Milton Mills RdActon, ME 04001PH: 207.636.2100FAX: 207.636.3045

We are committed to providing a website that is accessible to the widest possible audience, regardless of technology or ability. This website endeavors to comply with best practices and standards defined by Section 508 of the U.S. Rehabilitation Act.

700 Milton Mills Rd
Acton, ME 04001
PH: 207.636.2100
FAX: 207.636.3045