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2. This form is an initial step in processing your request for an accommodation under Title II of the Americans with Disabilities Act. An accommodation is a reasonable modification or adjustment that enables a qualified person with a disability to enjoy the same access to employment, facilities, services, activities and programs that are enjoyed by persons without disabilities.

   To determine whether you are eligible for an accommodation under the Americans with Disabilities Act, the Americans with Disabilities Act coordinator may ask for documentation of your medical condition. Having a medical condition alone is not enough to make you eligible for an accommodation. Under the Americans with Disabilities Act, a person with a disability must have a physical or mental impairment that substantially limits one or more major life activities, such as breathing, eating, sleeping, walking, talking, manual tasks, hearing, caring for oneself, standing, lifting and reading.

   The Americans with Disabilities Act requires the Americans with Disabilities Act coordinator to keep medical information confidential. However, the law allows the Americans with Disabilities Act coordinator to share information regarding your medical condition with individuals who are considered to have a legitimate need to know this information. These persons can include first aid and safety personnel, personnel investigating compliance with the Americans with Disabilities Act, and other persons considered to have a legitimate need to know. The law does not prohibit you from voluntarily discussing your condition or medical information with others.

   If accommodations are needed for an event, please allow as much time as possible prior to the event to process your request and make appropriate accommodations if they are approved.

4. Participant/requestor information
6. Date of request
   Date of request
8. Affiliation

   1. Resident
   2. Visitor

   1. Guest
   2. Volunteer

   1. Employee
10. First Name
11. Last Name
13. Address1
15. Address2
17. City
18. State
19. Zip
21. Email address
22. Phone number
23. Preferred method of contact

    1. Email
    2. Phone
    3. Mail
25. Reasonable accommodation request details
27. 1) Do you believe you have a disability or impairment that may limit you from having equal access to Town programs, services or activities?

    1. Yes
    2. No
29. 2) Please describe specific access barriers or problems you are experiencing that prevent you from having equal access, information or participation in Town services, programs or activities.
31. 3) Please describe the major life activity that is limited by your impairment or disability.
33. 3) Please describe the reasonable accommodation you are requesting, or indicate if you need assistance in identifying possible accommodations.
35. Contact information for health care providers:
37. Health care provider name
38. Health care provider phone number
40. Electronic signature*
    Please type your first and last name. I understand that this constitutes a legal signature.
Leave This Blank:


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

    This field is not part of the form submission.

44. Submit

* indicates a required field