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This form is to be used by individuals seeking a reasonable accommodation with respect to accessing a City program, service, activity, or facility pursuant to the Americans with Disabilities Act (Title II) and/or Section 504 of the Rehabilitation Act of 1973. The City is dedicated to providing reasonable accommodation to all qualified individuals with disabilities using its facilities or participating in its programs, services, and activities.
Please submit this request to one of the City officials listed at the bottom of page 2 of this form. If you need assistance completing this form, please contact one of these officials. Alternative means of submitting an accommodation request, such as by personal interview or telephone, may be made available upon request. A request for accommodation should be made as much in advance as practical; please contact the department offering the program, service, or activity should you have questions about how much advanced notice is required.
Accommodation requests related to the Murfreesboro Parks and Recreation Department’s programs, services, activities, and events should be submitted to:
Assistant Director, Murfreesboro Parks and Recreation Department
697 Veterans Parkway
Murfreesboro, TN 37128
Email Angela Jackson
All other accommodation requests should be submitted to:Robert HoltzChief Building Official, Building and Codes Department111 West Vine StreetMurfreesboro, TN 37130Phone: 615-893-3750Fax: 615-848-3248Email Robert Holtz
If yes, please provide that person’s age and sex.
Please note that the City may require additional information to evaluate this request and may ask that you or your representative submit a statement or other medical documentation from a healthcare provider.
I certify that I have, or the person on whose behalf I am requesting an accommodation has, a disability that requires reasonable accommodation to allow for full participation in a City program, service, or activity and that the information I have provided on this form is accurate and complete to the best of my knowledge.
This field is not part of the form submission.
* indicates a required field