This form is an initial step in processing your request for an accommodation under Title II of the ADA. An accommodation is a reasonable modification or adjustment that enables a qualified person with a disability to enjoy the same access to services, activities and programs that are enjoyed by persons without disabilities. If you need assistance completing this form, please contact the ADA Coordinator directly, at 970-542-3975.
Additionally, you may also call 221-6515 (V/TDD: Dial 711 for Relay Colorado) for assistance.

If accommodations are needed for an event, please allow four (4) business days prior to the event to process your request and arrange the accommodation, if approved. If you require additional space to provide your information, please attach any supporting documentation using the form below.

Full name:

Address:

City:

State:

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Zip Code:

Telephone Contact #:

Email:

Reasonable Accommodation Request Details

Activity, Event or Item name

Activity, Event or Item Location

Activity, Event or Item Date

Requested Accommodations: Please provide the accommodation you are in need of and any additional details to assist us in reviewing your request.

Please type your name in the space to provide an electronic signature

Today date: