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ADA Request for Reasonable Accommodation Form

2. Applicant Information

3. Date
   Date

5. First Name*

6. Last Name

8. Address1*

10. Address2

12. City

13. State

14. Zip

16. Emergency Contact(s):

18. Email

20. Contact Number(s)

22. Nature of your disability: *

    1. Visual
    2. Hearing
    3. Physical
    4. Learning/Mental
    5. Other, Please specify below

24. Please Specify

26. Request Date*

28. Request Time and Duration*

30. Event and Location

32. Please describe your preferred method of reasonable accommodation:

34. Please check the checkboxs below:*

    1. I have reviewed and understand Hall County's ADA Notice and Policy.

36. Modification Request
    A reasonable modification may not be granted if taking that action would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.

    A reasonable modification may not be granted if taking that action would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field