Accommodation Request Form

Requests for reasonable accommodation under the ADA should be requested as far in advance as possible. To request accommodation, complete and return this form to the ADA Coordinator identified below. If you need help completing this form, contact the ADA Coordinator directly for assistance. To properly evaluate your request, you will be contacted to discuss the request further and then you will be provided with a written response. If your request is denied, you may request further review in accordance with the ADA grievance procedure.



City or Town:

State or Province:

Zip or Postal Code:



What type of service, activity, or program will you be attending? 

At which county facility is the service, activity, or program located?

On what date or time-frame are you requesting accomodation?

For what type of impairment are you requesting accomodation?

What accommodation(s) are you requesting?


If you need a print version of this form, please contact the Human Resources Office at 269-781-0992 or 315 W Green St., Marshall, MI 49068.