Citizen Accommodation Request and Concerns

Americans with Disabilities Act Plan

Instructions:
Please fill out this form completely and Submit below.

If you are unable to complete this form due to a disability or need additional information, please contact the ADA Coordinator at 423.753.1030 for assistance, and the Town, to the extent possible, will make reasonable accommodations.

Confidentially:
Information contained on this form will be classified as CONFIDENTIAL to the extent permitted by law. Information obtained or generated in the processing of the accommodation request may be released to individuals of Town departments or agencies participating in the evaluation or provision of the accommodation requested.

Requester:

Name*

Address*

Email*

Phone Number*

1. Is the accommodation request related to a Town event, program or accessibility issue?

Event/Program Name:

Event/Program Date:

Accessibility Issue Location:

2. What is the barrier which prevents you from participating or the nature of the accessibility issue?

3. Describe accommodation requested:*

4. How will the accommodation requested help relieve any roadblock to your satisfactory participation?*

5. Any other concerns or difficulties?*

Signature*

Date Submitted*

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