ADA REASONABLE ACCOMMODATION REQUEST FORM MEMBER

FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY

The Greater Joliet Area YMCA will make every attempt to make reasonable accommodations for members and program participants requesting special assistance. If you have an accommodation request, please complete the Accommodation Request Form below and attach your doctor's note, if applicable, describing the disability for which you are requesting accommodation.

Completion of this form, will allow the YMCA to assess the accommodation needs for the Greater Joliet Area YMCA's programs, services and activities. This may include but is not limited requesting physical accomodations, alternative formats/communications and modifications of policies and procedures.

*The Americans with Disabilities Act (ADA) does not require the YMCA to take any action that would fundamentally alter the nature of its programs or services or impose an undue financial hardship.

Date*

Date

Name*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Current Y MemberCurrent Y ParticipantPotential Y Member or Participant

Home branch*

Please describe the nature, extent & duration of your requested accommodation:*

Specify the program, service or activity for which you seek accommodation: *If requesting for a childcare program, please specify the location.*

Describe the accommodations you believe are needed to enable you to use our facility and or program, including requesting alternative formats, communications, and modifications of policies and procedures:*

Please upload your doctor's note

Thank you. Your request will be reviewed and you will hear from the Y staff within two business days of submitting this form.