Request for Reasonable Accommodation

Reasonable Accommodation Request Form

To complete your request you must provide a statement on letterhead from your licensed professional pertaining to your request. This statement must be provided to kteague@planoha.org or via mail or fax.

The following person in my household has a disability:
Name*

First NameLast Name
In the Explanation below describe how the accomodation will help you take part in our program or help you meet other requirements of our program.

Do NOT tell us medical information about your disability.

Do NOT tell us the name of your disability or the nature or extent of your disability.
Please provide the following reasonable accommodation:*
I need this reasonable accommodation because:*
Head of Household Name:*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Email*
example@example.com
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Signature*

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