Form Center • ADA Reasonable Accommodation Request

Introduction

Introduction
Purpose
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.
Instructions
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.
Please return this form as follows:
Accommodation requests related to the Murfreesboro Parks and Recreation Department’s and Golf Department's programs, services, activities, and events should be submitted to:
Angela Jackson
Executive Director, Strategic Services
697 Veterans Parkway
Murfreesboro, TN 37128
Phone: 615-890-5333
Email Angela Jackson
All other accommodation requests should be submitted to:
Kevin Jones
Director, Building and Codes Department
111 West Vine Street
Murfreesboro, TN 37130
Phone: 615-893-3750
Fax: 615-217-3016
Email Kevin Jones
Continue

Section A

Section A: Individual Seeking Reasonable Accommodation
First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Day Time Telephone*
Cell Phone
Email*
Work Phone
Is the person needing reasonable accommodation under the age of 18?*
1. Yes
2. No
If yes, please provide that person’s age and sex.
Age
Sex
1. Male
2. Female
3. Other / I Prefer Not to Answer
Continue |Go Back

Section B

Section B: Individual making request (if other than person identified in Section A)
First Name
Last Name
Address1
Address2
City
State
Zip
Day Time Telephone
Cell Phone
Email
Work Phone
Relationship to person seeking an accommodation
Continue |Go Back

Section C

Section C: Please provide the following information regarding this accommodation request.
City department(s) or facilities(s) associated with the program, service, or activity that applicant wishes to utilize or attend: *
Date(s) accommodation needed: *
Date(s) accommodation needed: Start Date
—
Date(s) accommodation needed: End Date
Please describe the accommodation(s) you are requesting. If you are not sure what accommodation(s) you need, please provide any suggestions on possible options.*
Please describe how the accommodation(s) requested or suggested will facilitate access to the program, service, activity, or facility.*
Please provide any additional information that will help the City evaluate your request, including any pertinent information about the nature of the disability and functional limitation(s) that are the basis of the request.
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.
Continue |Go Back

Section D

Section D: Certification of Disability and Need for Reasonable Accommodation
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.
By entering my name here I agree to the above statement.*
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit | Go Back

Search Forms:

ADA Reasonable Accommodation Request - Access to City Program, Service, Activity, or Facility (FORM 2008B, Revised 12/14/2020)

Steps

Introduction

Section A

Section B

Section C

Section D

Connect With Us