ADA Accommodation Request Form

ADA Accomodation Request Form

SECTION 1: Requester Information

Name

Address

Phone Number

Email Address

Preferred method of contact

Phone Email Mail Other

If this request is made on behalf of another person, please provide that person's:

Full name

Street address

Primary phone number

Primary email address

What is your relationship (optional, no specific relationship is required to make a request on behalf of a person with a disability)?

If other please describe here

May we contact this individual directly

Yes No

Preferred contact method

Phone Email Mail Other

Section 2: Program, Service, Activity, or Event

Name of program service or event

Department

Location

Date or dates of participation

Section 3: Accomodation Requested

Disability-related information will be kept confidential and shared only with staff who need the information to evaluate or respond to this request. Describe the accommodation, modification, auxiliary aid, or service requested. Please be as specific as possible (e.g., accessible seating, materials in accessible format, ASL interpreter, etc.)

Describe your request here

Section 4: Functional Need for Accommodation

Describe the functional need creating the need for accommodation. (Optional, Unless Requested When Need Is Not Obvious). You do not need to disclose a diagnosis or medical history.

Describe your need below

Section 5: Supporting Documentation (Optional, unless requested when need is not obvious)

Upload any documentation (e.g., statement from a provider, 504 plan or IEP, etc.) below:

File Uploader

Section 6: Time Sensitivity

Is the request time sensitive

Yes No

If yes, please explain any deadlines or dates the District should know about:

Explain deadlines or dates here

Section 7: Authorized Communication

I agree to receive communications regarding this request at the contact method selected above:

Select one

Yes No

Certification

I certify that the information provided is accurate to the best of my knowledge.

Check box to agree

Type your name below

Date

Fill out the following form to submit an Americans With Disabilities (ADA) Accommodation Request

ADA Accomodation Request Form

SECTION 1: Requester Information

Section 2: Program, Service, Activity, or Event

Section 3: Accomodation Requested

Section 4: Functional Need for Accommodation

Section 5: Supporting Documentation (Optional, unless requested when need is not obvious)

Section 6: Time Sensitivity

Section 7: Authorized Communication

Certification