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Reasonable accommodation request form

  1. This form is an initial step in processing your request for an accommodation under Title II of the Americans with Disabilities Act (ADA). 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 ADA, the ADA 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 ADA, 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 ADA requires the ADA coordinator to keep medical information confidential. However, the law allows the ADA 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 ADA, 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.

  2. Affiliation

  3. Preferred method of contact

  4. 1) Do you believe you have a disability or impairment that may limit you from having equal access to Town programs, services or activities?

  5. Please type your first and last name. I understand that this constitutes a legal signature.

  6. Leave This Blank:

  7. This field is not part of the form submission.