ADA Request for Accommodation Form

2. ADA Public Request for Accommodation

4. Your name*

5. Your phone number*

7. Your address*

9. City*

10. State*

11. Zip*

15. Name of person requesting accommodation

    Complete this section if the individual requesting accommodation is not the individual completing this form.

16. Phone number

18. Address

20. Address

22. City

23. State

24. Zip

28. Program/facility alleged to be inaccessable*

30. 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.

32. Photo of program/facility that is not accessible

    If possible, please share a photo of program/facility that is not accessible

34. 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.

36. Proposed accommodation/resolution*

    How would you propose to make the program/facility accessible?

38. E-signature*

39. Today's date*
    Today's date

Leave This Blank:


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

    This field is not part of the form submission.

43. Submit

* indicates a required field