4. VILLAGE OF ROMEOVILLE
6. ADA ACCOMMODATIONS REQUEST FORM
8. Description:
   The Village of Romeoville will make all reasonable modifications to policies and programs to ensure that people with disabilities have an equal opportunity to enjoy all Village programs, services and activities.
   
   To request accommodations, complete the following form.
12. DETAILS AND LOCATION
14. Accessible Format Needed

    1. Assistive Listening Device
    2. Large Print

    1. Sign Language Interpreter
    2. TDD
16. Other (please describe)
18. Requestor is...
    -- Select One --ResidentDefendantVillage staff member on behalf of a residentAdvocateAttorneyOther
19. Describe the services needed (e.g. service, program or activity)
    -- Select One --Access to a village building entrance, village parking, etc.Accomodation to participate in village programAccomodation needed to participate in village activityCourt ServicesOther
21. Date and Time Assistance is Needed:
    Date and Time Assistance is Needed: Start Date

    Date and Time Assistance is Needed: Start Time

    —

    Date and Time Assistance is Needed: End Date

    Date and Time Assistance is Needed: End Time
22. Reason for Accommodations:
24. Additional Information if Needed:
28. CONTACT INFORMATION
30. Name
31. Email Address
33. Address
35. City
36. State
37. Zip Code
39. Phone Number
40. Fax Number
Leave This Blank:


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

    This field is not part of the form submission.

44. Submit

* indicates a required field