Fillable Auxiliary Aids And Services Request Form (City of Brighton)

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Auxiliary Aids And Services Request Form (City of Brighton)

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City of Brighton
500 South 4
th
Avenue
Brighton, CO 80601
303-655-2000 Office
www.brightonco.gov
Email: ada@brightonco.gov
Auxiliary Aids and Services Request Form
Please fill out this form completely in print or type. Sign and return to the ADA Coordinator via email, fax,
mail or in person. Requests are processed as quickly as possible. If you require assistance completing this
form, please contact the ADA Coordinator.
Qualified Individual Information:
FIRST NAME LAST NAME
________________________________ ____________________________________
DAYTIME PHONE (Please include area code) ALTERNATE PHONE (Please include area code)
________________________________ ____________________________________
MAILING ADDRESS CITY
________________________________ ____________________________________
STATE ZIP CODE EMAIL ADDRESS (If available)
____________ _______________ ____________________________________
How would you like us to contact you?
Email Mail Telephone Other (specify) _________________________
Please state the City program, activity or service in which you need to use an auxiliary aid or
service. Note that if your request requires a response in a certain timeframe or is related to
a specific event, please provide the date and time of the event.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please describe the auxiliary aids or service needed, including the reason and purpose, and
provide any supporting documentation necessary to assist in processing the request. Attach
additional pages if needed.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please sign and date this request. You do not need to sign if submitting this form by email,
just type your name.
Date: ____________________
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.
For Administrative Use Only:
Action taken:
Date received:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
ADA Coordinator Signature: _________________________
Date Completed: ________
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Auxiliary Aids And Services Request Form (City of Brighton)

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Completed 14 July 2020

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