Request for Accommodation

1

The City of Greensboro provides accommodations for people with disabilities or special needs to allow everyone to take part in public meetings and events. Submit the following information to request an accommodation. The accommodation request should be made no later than three business days prior to the meeting or event, preferably a week in advance for the appropriate services to be scheduled.

Someone will contact you within three (3) business days to discuss this information and any additional accommodation, support and service that may be necessary.

Upon request, reasonable accommodation will be provided in completing this form or copies of the form will be provided in alternative formats. If you need assistance in completing the request form, contact The ADA Coordinator, Gary Canapinno at 336-373-2723.

This online form is subject to the public records law. This communication is not confidential. All threats and harassment will be logged.

*denotes a required field

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Requestor's Name* This field is required.

First Name

Last Name

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Contact Person if other than the requestor

First Name

Last Name

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Phone Number* This field is required.

Area Code

Phone Number (and extension if applicable)

5

Cell Number

Area Code

Cell Number (and extension if applicable)

6

E-mail

example@example.com

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Program/Meeting Title* This field is required.

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Program/Meeting Location* This field is required.

9

Program/meeting Date(s) and Time(s)Choose a program/meeting date and/or time. To choose more than one day/time, click the +Add Another Date and Time Button.

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Accommodation Requested* This field is required.

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Today's DateField is auto-populated with today's date

Date