Request for Accommodation for a Person with a Disability

If you require an accommodation under the Americans with Disabilities Act (ADA) for a program or service, it is recommended that you make your request at least two weeks in advance in order to allow the City & County of Broomfield time to review your request and make arrangements for the accommodation. All requests for accommodation, regardless of timeliness, will be given due consideration and if necessary, may require an interactive process between the requester and the Recreation Department to determine the best course of action.

When you are done completing this form, please hit the "submit" button below. You will be notified by email once a decision is made on your request. Additional information may be needed to process your ADA request.

Sign in to Google to save your progress. Learn more
Email *
Please explain the type of accommodation(s) requested and any special requests or anticipated problems. Primary consideration will be given to the requested accommodation; however, the City Of Broomfield reserves the right to offer an alternative accommodation if one is more readily available and equally effective in accommodating your needs* *
Please describe the limitation necessitating accommodation. *
Name *
Address
City
State
Zip Code
Phone Number *
Is this a TDD number? *
Required
Please provide the date, time and location that an accommodation is requested. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of The City and County of Broomfield.

Does this form look suspicious? Report

Google Forms