Request an Accommodation – Greeley Forms

If you need assistance completing this form, please contact the ADA Coordinator directly, at 970-336-4029, [email protected], or V/TDD 711.

Reasonable Accommodation Request Form

This form is an initial step in processing your request for accommodation under Title II of the ADA. An accommodation is a reasonable modification or adjustment that enables a qualified person with a disability to enjoy the same access to services, activities and programs that are enjoyed by persons without disabilities. If accommodations are needed for an event, please allow four business days prior to the event to process your request and arrange the accommodation, if approved.

Participant/Requestor Information

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Reasonable Accommodation Request Details

Activity/Event

Activity/Event Location

Activity/Event Date

Requested Accommodation

Braille

Large Print

Sign Language Interpreter

Assistive Listening Device

Other Service or Aid

Policy or Practice Modification

lf you require additional space to provide your information, please complete the section below.

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