Reasonable Accommodation Request Form (The Lincoln Center)

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 three weeks 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.

1. Requestor Information: *This question is required.

Full Name:

Street Address:

City:

State:

Zip Code

Telephone Contact Number:

Email:

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

Event Name:
Event Location:
Event Date:
Event Time:

3. If you plan on attending a ticketed event, have you already purchased tickets?

4. What is your order number?

4. Requested Accommodation (Please select all that apply):

Braille
Large Print
ASL/Sign Language Interpretation
Assistive Listening Device
Policy or Practice Modifications Request
Other service or assistance (please provide details in Question #5 below)

5. If attending a ticketed performance, would you like to request any additional seating-related accommodations?

Wheelchair
Walker
Scooter
Bariatric Chair
Service Animal (Service animals are welcome, however, emotional support animals and pets are not accepted.)
Mobility Assistance (Please describe mobility assistance need in the space below.) (Ex. 1. Need wheelchair transport from parking lot to lobby. 2. Need seating space to accommodate walking boot/air cast on right foot. etc.)
Other Assistance (Please provide details in the space below.)

6. If you use a mobility aid, would you prefer to stay in your wheelchair, walker or scooter or, would you prefer to transfer to a theater seat?

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

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

File: {{filename}} delete

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