I am a deaf person. As such, I am a person with a disability under the meaning of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973 as amended, and the Michigan Persons with Disabilities Civil Rights Act. Pursuant to all applicable laws, I am requesting the following auxiliary aids and/or services as a reasonable accommodation.

Sign Language Interpreter Oral Interpreter Notetaker Services

Hotel Room Accessible for Deaf or Hard of Hearing Person

Accommodation Request Information:

Location: __________________________________________________________________

Address: __________________________________________________________________

Time: __________________________________________________________________

Preference(s) __________________________________________________________________

_____________________________________________________________________________

This request is made to (Name of Person receiving request) _________________________________

Of (Name of agency or organization) _____________________________ Date:_____________________

___________________________________
(Print Name)

___________________________________
(Signature)

ADA Information Line: 800-514-0301 (voice) 800-514-0383 (TDD) ADA website: http://www.usdoj.gov/crt/ada/adahom1.htm
Michigan Division on Deaf and Hard of Hearing: 877-499-6232 V/TTY
DODHH website: http://www.michigan.gov/cis/0,1607,7-154-28077_28545_28559---,00.html
Copyright Celeste Johnson, 2003. Reprinted with permission. This form may be freely reproduced and distributed on the condition that this notice appears on all copies.