Request for Accommodation for services through The City of Peoria Community Services Department Dear Applicant, The Community Services Department is pleased to provide you with a Request for Accommodation form as part of its commitment to the Americans with Disabilities Act (ADA). The Act was designed to remove barriers to full participation in public programs by individuals with disabilities. Successful accommodation requires careful planning and coordination. The Request for Accommodation form is designed to help the Community Services Department’s ADA Review Committee evaluate the needs of the participant and plan accordingly. It is advisable that forms be completed at least two weeks prior to the start of an activity or program, as some requests can take up to a week to review and another week or more to arrange. A member of the Committee will be in contact with you within 2 weeks after applying for an accommodation. Commonly Asked Questions: What is a reasonable accommodation? Accommodation can take many forms. Each accommodation is on a case-by-case basis and may include, but is not limited to: changing program procedures, providing auxiliary aids, making accessibility modifications, staff training and technical assistance. The ADA Review Committee will determine the degree of accommodation needed for each participant and will monitor progress throughout participation in the program or activity, providing adjustments when the need arises. What if I am not sure about the most appropriate accommodation? The Department’s Adaptive Recreation Program provides year-round activities for individuals with disabilities. Youth programs provide accommodations for those who meet the criteria. Staff from each Program is available to discuss any questions or concerns as they relate to the accommodation. The number for the Adaptive Recreation Program and Special Interest Classes is 623-773-7436. AM/PM, Summer Recreation, Summer Camp and Sports questions can be directed to 623-773-7108. What documentation should I provide? There are a number of documents that can accompany a request. These will be utilized in verifying a disability and assisting the ADA Review Committee in planning an accommodation. A few of the forms that can be used when applying for an accommodation are; a child’s I.E.P., medical records and/or doctor’s diagnosis, provided that enough information is included to facilitate an accommodation. This documentation will be evaluated to determine if there is a need for accommodation and to what degree it is needed. How long is the Request for Accommodation good for? The Request for Accommodation would need to be completed prior to admission into a program. Accommodations may vary from activity to activity, so separate requests need to be done for separate activities. Accommodations can be modified over time to meet the needs of the participant. If a Request for Accommodation was completed for the AM/PM program, it would be in effect throughout the school year and would need to be re-submitted the following school year, if an accommodation was still needed. As mentioned before, requests should be submitted at least two weeks prior to the beginning of a program. What services are not provided under the ADA? The ADA identifies areas that are not considered a reasonable accommodation and are exempt under the ADA. Department staff do not provide services of daily living that include feeding, dressing, and toileting. Serious behaviors that can jeopardize the health and safety of others or are a serious disruption to the program (i.e. abusive language, hitting, kicking) can be grounds for denial or removal from a program. The Department will assist in dispensing most medications during program hours, however clear instructions must be provided and medication should be sent in the original prescription bottle. Staff does not administer injections of any kind. Program Policies and Procedures Policies and procedures that relate to participation criteria including, but not limited to, age, residency, or grade level are not altered as an accommodation. Other policies and procedures can be reviewed and modified as needed to allow for successful participation in a program. If you have additional questions regarding accommodation, please feel free to contact the Community Services Department at 623-773-7137 or the Adaptive Recreation Program at 623-773-7436. Rev. 5/22/03 REQUEST FOR ACCOMODATION City of Peoria Community Service Department Recreation Division The city of Peoria endeavors to make all of its programs accessible to individuals with disabilities in accordance with The Americans with Disabilities Act. In order to better serve citizens who require accommodation, this form needs to be completed as thoroughly as possible prior to program registration. Child’s Name: __________________________________________ D.O.B.:____/____/____ Age: ________ Current School Attending: ______________________________ Parent Name Mother:____________________________ Cell Phone: (______) ________ - _______________ (If a minor or if Parent has guardianship) Parent Name: Father - ____________________________ Cell Phone: (______) ________ - _______________ Home Phone: (______) ________ - _______________ Work Phone: (______) ________ - _______________ Check Program Desired: Start Date: ? Adaptive Recreation ? AM/PM Program - Name of School _______________________________________ ? Summer Camp – Site Location___________________________________________ ? Tiny Tots - Site Location ________________________________________________ ? Summer Recreation, Grades 1-5 - Site Location ____________________________ ? STEP OUT- Site Location ________________________________________________ ? Sports - Name of Sport _________________________________________________ ? Aquatics – Name of Program or date of Lesson _____________________________ ? SIC – Name of Class ___________________________________________________ Complete questions 1- 4 fully with as much detailed information as possible. Documentation of a Disability from your Physician, Health Care professional or School District is REQUIRED FOR ACCOMODATIONS. Provide as much information as possible to allow the staff who is or are a Certified Therapeutic Recreational Specialist to properly assess the level of accommodation needed. Attach additional documentation, such as, the child’s I.E.P., medical records and/or a doctor’s diagnosis to the request. Please do not use abbreviations. 1. Name of Disability: _________________________________________________________________________ 2. Type of Documentation providing: ____________________________________________________________ 3. Describe the desired accommodation you are requesting: _________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. Participation Concerns/Special needs: _________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Please cont. on next page) REQUEST FOR ACCOMODATION City of Peoria Community Service Department Recreation Division Child’s Name: _______________________________________ Participation Concerns/Special needs continued: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I have hereby requested the above accommodation and affirm that I am a qualified individual with a disability pursuant to the Americans with Disability Act. I also confirm that I have reviewed the department’s informational packet regarding a Request for Accommodation. Signature Signature of Parent/Guardian or if Minor Date TO BE COMPLETED BY THE CITY Date Received: _____/_____/_____ Received by staff and School name (if applicable): _____________________________________________________ Reviewed: _____/_____/_____ Contact Date: _____/_____/_____ S.A. Staff: ____________________________ Action Taken:________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CTRS reviewed and completed by: __________________________________________