Reasonable Accomodation Request Form (English)

Reasonable Accommodation Request Form (English)

Reasonable Accommodation Request Form

Haga clic en este enlace para ver este formulario en español.

This form is an initial step in processing your request for an 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 you need assistance completing this form, please contact the ADA Coordinator directly, at 970-416-4254 or adacoordinator@fcgov.com. Additionally, you may also call 221-6515 (V/TDD: Dial 711 for Relay Colorado) for assistance.

If accommodations are needed for an event, please allow four (4) business days prior to the event to process your request and arrange the accommodation, if approved. If you require additional space to provide your information, please attach any supporting documentation using the form below.

If you need assistance in completing this form, including interpretation or translation assistance, please contact the City's ADA Coordinator via email, at adacoordinator@fcgov.com or by calling 970-416-4254.

PLEASE COMPLETE THE INFORMATION BELOW:

1. Requestor Information *This question is required.

Full name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

2. Reasonable Accommodation Request Details *This question is required.

Activity, Event or Item Name

Activity, Event or Item Location

Activity, Event or Item Date

3. Requested Accommodation (Please select all that apply) *This question is required.

Braille
Large Print
ASL/Sign Language Interpretation
Assistive Listending Device
Policy or Practice Modification Request
Other service or assistance (please provide details in the text box below)

4. Please provide any additional details to assist us in reviewing your accommodation request.

5. Please upload any supporting information or documentation to assist us in reviewing your accommodation request.

File: {{filename}} delete

6. Type your name in the space below to provide an electronic signature.

7. Today's date: This question requires a valid date format of MM/DD/YYYY.

calendar

8. In order to receive a copy of this complaint, please enter your email below: This question requires a valid email address.