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ADA Request for Accommodation Form
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ADA Public Request for Accommodation
Your phone number
Name of person requesting accommodation
Complete this section if the individual requesting accommodation is not the individual completing this form.
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 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.
How would you propose to make the program/facility accessible?
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