Accessibility Request Form

Larimer County is committed to ensuring equal access to all programs, services, and activities in accordance with Title II of the Americans with Disabilities Act (ADA). If you are a person with a disability and need a reasonable accommodation to access a County service or participate in an event, or if you wish to file a formal complaint (grievance) regarding accessibility or discrimination based on disability, please complete the form below.

This form may be used to:

Request an accommodation for a County meeting, service, or program
Report an accessibility barrier or concern
File a grievance if you believe your rights have been violated

You are not required to disclose medical details beyond what is necessary to process your request. All information will be kept confidential and used solely for the purpose of evaluating and responding to your submission.

If you need assistance completing this form or wish to submit your request in another format, please contact our Accessibility Coordinator at (970) 498-5967 OR email at accessibility@larimer.org.

All fields marked with * are required and must be filled.

Section 1: Name and Contact Info

First Name

Last Name

Preffered Method of Contact:

	Email
	SMS (Text message)
	Telephone Call

	US Mail
	TTY (teletypewriter)
	Other

Email Address *

Phone Number *

TTY (teletypewriter)

Confirm SMS

Check here to confirm number can receive text messages *

Your Address:

Address (Lookup)

Street Address

Street Number

Unit Number (optional)

Street Name

City

State

Postal Code

Notify ADA Coordinator of an Accessibility Issue

Type of Issue

	Digital Services Issue (Website or Online Application)
	Facilities Accessibility Issue
	Accessibility Issue experienced at an Event or Meeting

Event Date

Event Time

Event (Hour)

Event (Minute)

Event (AM / PM)

Event Time

Facility / Location

Name of Web Page, Digital Service or Application

URL (if available)

Description of Issue

Request for an Accessible Accommodation

Type of Request:

	Digital Request
	Facilities Request
	Event / Meeting Accommodation Request

Event Date

Event Time

Event (Hour)

Event (Minute)

Event (AM / PM)

Event Time

Facility / Location

Name of Web Page, Digital Service or Application

URL (if available)

Description of Request

File a complaint /grievance

I also wish to file a formal complaint / grievance

Note: Parent or Legal Guardian may sign on behalf of minor child. Legal Guardian, Power of Attorney or equivalent may sign on behalf of adult – documentation is required.

By typing your name and submitting this form, you certify that to the best of your knowledge this information is true and correct.

	Request an accommodation for a County meeting, service, or program
	Notify the ADA Coordinator of an Accessibility Issue