Accommodation Request Form

The City of Pleasnaton's Library and Recreation Department welcomes and encourages individuals of all abilities to participate in City programs, activities, camps, and classes.

This form is used to request reasonable accommodations, modification, services, or other inclusion supports that may help a participant access and participate in a Recreation program or activity. Inclusion supports are considered through an individualized review process and are intended to meet participant needs in ways that are reasonable, safe, and do not fundamentally alter the nature of the program or activity.

Please complete this form if you or your child may need supprot to participate. Requests should be submitted as early as possible before the program begins to allow time for review, coordination, and implementation. City staff may contact you for additional information as part of the review process.

The City of Pleasanton is committed to providing inclusive recreation opportunities consistent with the Americans with Disabilities Act and the City's commitment to promoting facilities and activities that accommodate community and family use and persons of all abilities.

Participant Information

Name

First NameLast Name

Date of Birth

Date

Age

Grade (if applicable)

Activity Information

Please list all the activities you are signed up for or intersted in (add a row for additional activities). Also list all corresponding activity codes (if available):

Activities

Activity Codes

Start Date

Date

Has the participant already registered for the program?

Accommodation Request

Please use the space below to describe your participant's need for accommodations:

Are there any safety/behavioral concerns for the participant in this program or activity?

Parent/Guardian Name (If applicable)

Name

First NameLast Name

Relationship to Participant

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Acknowledgement

I understand that submitting this form does not guarantee that a specific accommodation, modification, auxiliary aid, service, or support will be provided exactly as requested. The City will review the request on an individualized basis and may contact me for additional information as part of the review process.

Please submit this form as early as possible before the program begins. Late requests will be reviewed; however, some accommodations or supports may require additional time to arrange.

Information provided on this form will be used to evaluate, coordinate, and implement the requested accommodation or support. Information will be kept confidential to the extent permitted by law and shared only with City staff, contractors, instructors, volunteers, or service providers who need the information to evaluate, coordinate, or implement the requested accommodation or support.

Signature

Date