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ADA Public Request for Accommodation

First Name*
Last Name*
Address1*
Address2*
City*
State*
Zip*
Your Phone Number*
Name of person requesting accommodation
Complete this section if the individual requesting accommodation is not the individual completing this form.
Phone Number
Address1
Address2
City
State
Zip
Program/Facility alleged to be inaccessable*
Description of the situation or way the Program/Facility is not accessible*
Please provide names of individuals who were involved in the situation and include as much detail as possible.
Photo of Program/Facility that is not accessible
If possible, please share a photo of the Program/Facility that is not accessible
Description of your disability*
Please explain the nature of your disability that limits your ability to participate, and how it impairs a major life function.
Proposed accommodation/resolution*
How would you propose to make the program/facility accessible?
E-Signature*
Please type your full name
Today's Date*
Today's Date
mm/dd/yyyy

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1. Receive an email copy of this form.
Email address

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