ADA Accommodation Request Form

This form is intended for individuals requesting reasonable accommodations under the Americans with Disabilities Act (ADA). It helps facilitate communication between the requesting party and the responsible department or authority to ensure compliance with applicable accessibility requirements.

Contact Information

Full Name: {fullName}

Phone Number: {phoneNumber}

Email Address: {email}

Mailing Address: {address}

Accommodation Request Details

Date of Request: {requestDate}

Event/Program/Service Name: {serviceName}

Date of Event or Expected Accommodation: {eventDate}

Location (if applicable): {location}

Describe the disability or condition for which you are requesting accommodation:

{disabilityDescription}

Describe the specific accommodation(s) being requested:

{accommodationDescription}

Medical or Professional Documentation

{#hasDocumentation}

Medical documentation is provided with this request.

{/hasDocumentation}

{^hasDocumentation}

No medical documentation has been submitted.

{/hasDocumentation}

Communication Preferences

{communicationPreference}

Emergency Contact

Name: {emergencyContactName}

Relationship: {emergencyContactRelationship}

Phone Number: {emergencyContactPhone}

Previous Accommodations

{#previousAccommodations}

• {title}: {details}

{/previousAccommodations}

{^previousAccommodations}

The requester has not received any prior accommodations.

{/previousAccommodations}

Supporting Individuals

The following individuals are supporting this request:

Signature

Signature: ____________________________

Date: {signatureDate}

For Office Use Only

Status: {status}

Reviewer Comments:

{reviewComments}