Modification Form

Modification Form
The City of Peoria strives to make all of its programs, meetings, and buildings accessible to individuals with disabilities in accordance with the Americans with Disabilities Act. In order to better service citizens who require modification, this form needs to be completed prior to event date.
Individual’s Name*
Date Of Birth*

MonthDayYear
Age*
Guardian Name*
Please enter N/A if not applicable
Cell Phone*
Home Phone
Work Phone
Email Address*
example@example.com
Program/Activities Details
Attending/Registering*
Event Code
Location*
Date of event/activity*

MonthDayYear
Date
COMPLETE WITH AS MUCH DETAILED INFORMATION AS POSSIBLE
What is the identified disability?*
Describe the desired modification that you are requesting:*
By entering my name below I affirm that I have hereby requested the above modification and that I am a qualified individual/guardian of an individual with a disability pursuant to the Americans with Disabilities Act (ADA).*
Enter your name
I have hereby requested the above modification and that I am a qualified individual/guardian of an individual with a disability pursuant to the Americans with Disabilities Act (ADA).*

Clear
Date*

MonthDayYear
Date
Should be Empty: