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2. 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 970-332-4431 or adacoordinator@cityofwray.org. 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. 

   If you need assistance in completing this form, including interpretation or translation assistance, please contact the City's ADA Coordinator via email, at adacoordinator@cityofwray.org or by calling 970-332-4431.  

4. PLEASE COMPLETE THE INFORMATION BELOW:
6. 1. Requestor Information
8. First Name*
9. Last Name*
11. Email Address*
12. Phone Number*
14. Address
16. City
17. State
18. Zip Code
20. 2. Reasonable Accommodation Request Details
22. Activity, Event, or Item Location*
24. Activity, Event, or Item Name*
26. Activity, Event, or Item Date*
28. 3. Requested Accommodation (Please select all that apply)

    1. Braille
    2. Large Print
    3. ASL/Sign Language Interpretation
    4. Assistive Listening Device
    5. Policy or Practice Modification Request
    6. Other
30. 3.1 Please provide details for other requests
32. 4. Please provide any additional details to assist us in reviewing your accommodation request
34. 5. Please upload any supporting information or documentation to assist us in reviewing your accommodation request
36. Today's Date
    Today's Date
38. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature
42. Please enter your email address below if you would like a copy of this form.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field