Submit by Email
MECKLENBURG COUNTY
Park and Recreation Department
Therapeutic Recreation Division
Program Accommodation Request
Date: ______/______/______
Participants Name: ______________________________________________________________
Disability(s):
___________________________________________________________________
Date of Birth: ______/______/______
Program You Are Requesting Accommodates For: ____________________________________
Please note: The accommodations are based on the needs of the participant and the
purposes of the program.
Type of Accommodation Being Requested (check all that apply):
_____ Braille or Large Print Documents
_____ Change in rules and policies
_____ Behavior Support Plan
_____ Architectural Accessibility
_____ Increased Supervision
_____ Hand Over Hand Instruction
_____ Adaptive Equipment/
Adaptation of Activities
_____ Sign language interpreter or other
alternative communication devices
_____ Unsure / Other (please describe): _____________________________________________
Contact Name: ___________________________________ Phone Number: (____) _____-_____
Email Address: _________________________________________________________________
Preferred Means of Contact:
_____ Phone
_____ Email
-------------------------------------------------------------------------------------------------------------------For Staff Use
Date Received: _____/_____/_____
Meeting Date: _____/_____/_____
Staff Recommendations: _________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
Staff Member Reviewing: ________________________________
Date: 10/22/07
PEOPLE y PRIDE y PROGRESS y PARTNERSHIPS
5841 Brookshire Boulevard x Charlotte, North Carolina 28216-2403 x (704) 336-3854 x Fax (704) 336-5472
www.parkandrec.com
All services are available without regard to origin, sex, or disability
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