Request for special accommodation – NCR Council meeting

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Name *

Phone *

Email *

Meeting status *DelegateObserverGuest

Do you self-identify as a member with a disability? *

• Yes
• No

If yes, what are the functional limitations arising from your disability? (You do not need to disclose your diagnosis)

Do you need assistance if the room is evacuated? *

• Yes
• No

Do you require documentation an alternative media? *---NoAmerican Sign LanguageOral interpreter (For persons who are hard of hearing)Reader (For persons who are visually impaired)Real time captioningBrailleLarge PrintSound Amplification

If other, please specify

Dietary requirements or any allergies *NoneNut allergyFood restrictionOther

If other, please specify

Other comments

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