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ADA Request for Accommodation Form

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Participant First Name *
Participant Last Name*
Date of Request *
Date of Request
Parent or Guardian *
Address
City
State
Zip Code
Phone Number*
Email Address
Program Registering For*
Explain what disability you have that limits your ability to participate in a City of Kennewick program or service: (e.g. “I am confined to a wheelchair”, “I am hearing impaired”)*
Describe the program, service or activity you cannot access due to your disability and what you believe are the barriers to access or participation.*
Proposed Accommodation/Resolution:*