A.D.A. Accommodation Request

Personal and Contact Information:

Name of person needing accommodation:

Address of person needing accommodation:

Name of person filling out this form, if different than person needing accommodation:

E-mail address for contact if additional information is required:

Phone number for contact if additional information is required:

Accommodation Request Details:

Type of accommodation needed (What is your disability?):

Location of Court Appearance:

Date of Court Appearance:

Court Appearance Time: