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2. AMERICANS WITH DISABILITIES ACT (ADA) REQUEST FOR ACCOMMODATION

4. The City of Buckley is committed to making programs, services, and facilities accessible to all people. Under Title II of the ADA, the City of Buckley is required to ensure that our facilities, services, and programs are accessible to people with disabilities and in compliance with  the ADA. The city appreciates requests for accommodation to be made at least 72 hours in advance.

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6. First Name
7. Last Name
9. Physical Address
10. Apartment/Unit Number
12. City
13. State
14. Zip Code
16. Phone Number
17. Email Address
21. Describe the program, service or activity for which you are requesting an accommodation*
23. Date and time assistance is needed:*
25. Location of the program, service or activity:*
27. What do you believe are the barriers to access or participation:*
29. Proposed accommodation:*
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31. 1. Receive an email copy of this form.
32. Email address

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33. Submit

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