ADA Accommodation Request form - LACCD - Home
SERVICE REQUEST FOR ACCOMMODATION OR BARRIER REMOVALTitle II of the American with Disabilities Act Section 504 of the Rehabilitation Act of 1973 Please type or print legibly. CONTACT INFORMATIONName of person needing accommodation: _________________________________ Date of request: ______________ Address: _________________________________ City ___________________ State ______ Zip __________ Telephone Number: ________________________ E-mail address: __________________________________ Is the person needing an accommodation:Student □ Employee □ Visitor □ If person needing accommodation is not the individual completing this form, please provide your information: Name: _______________________________________ Telephone Number: _____________________ E-mail or Other Contact Information: ____________________________________________________________REQUESTCircle one: Accommodation Barrier Removal Accommodation needed or location of barrier: ___________________________________________________ _________________________________________________________________________________________ Brief statement of why the accommodation or the barrier removal is needed: _________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Program/Facility Location: ESC □ LACC □ ELAC □ LAHC □ MISSION COLLEGE □ PIERCE COLLEGE □ LATTC □ LAVC □ WLAC □ VAN DE CAMP □ Date accommodation is needed: ______________________________________________________________ Signature: __________________________________________________ Date: ________________________ Please submit the completed form to the College or Educational Services Center department where accommodation is needed. Please keep a copy of this form for your records and future reference. For more information or assistance in completing the form, please contact the ADA Compliance Administrator. Mardell Kuntzelman, ADA Compliance Administrator770 Wilshire AvenueLos Angeles, CA, 90015 (213) 891-2213 kuntzeme@email.laccd.edu ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- reasonable accommodation agreement sample letter
- final report of the best practices homepage
- ada accommodation request form laccd home
- ada reasonable accommodation lansing community college
- los angeles community colleges
- butler v the national collegiate athletic association ada
- technology for integration of students with disabilities
- americans with disabilities act ada
Related searches
- annual credit report request form pdf
- dhs hearing request form michigan
- credit report request form pdf
- medical records request form pdf
- equifax annual credit report request form pdf
- idr plan request form 2019
- nycha transfer request form pdf
- mandatory forbearance request form 2019
- supply request form pdf
- office supply request form pdf
- supply request form army
- office supply request form template