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 ................
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