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2. The City will make all reasonable modifications to policies and procedures to ensure that individuals with qualified disabilities have an equal opportunity to enjoy all City programs, services or activities. The City has the right, on a case-by-case basis, to determine whether a request is “reasonable” and whether or not the accommodation can be provided without jeopardizing the safe operation of the program, service or activity. The City shall not be required to make any modification that fundamentally alters the nature of the program, service or activity, or would result in undue administrative or financial burdens, as determined by the head of the department offering the program, service or activity. Requests for accommodation should be submitted as far in advance as possible, but not later than 48 hours prior to the need for the accommodation. Please use the form below to submit a request for a modification to policies or procedures in order to equally participate in City of Wichita Falls programs, services or activities or to request removal of architectural barriers in City facilities.
4. 1. Today's Date*
   1. Today's Date
6. 2. Contact Info
8. First Name*
9. Last Name*
11. Street Number*
12. Street Name*
13. Street Type*
14. Apt #
16. City*
17. State*
18. Zip*
20. Phone*
21. Email*
23. 3. Preferred Contact Method*

    1. Mail
    2. Phone
    3. Email
25. 4. Relationship to Applicant*

    1. Self
    2. Parent or Legal Guardian

    1. Spouse
    2. Other
27. 5. Type of Request (Select all that apply)*

    1. ASL Interpreter
    2. Assistive Learning
    3. Material in Braille
    4. Large Print
    5. Audio Recordings

    1. Curb Ramps
    2. Sidewalk
    3. Sire Modification
    4. Other
29. 6. Name or Address of facility for which the accomodation is being requested*
31. 7. Name of program, service or activity for which the accommodation is being requested.
33. 8. Department offering the program, service, or activity (if applicable).
35. 9. Date of program, service, or activity.*
    9. Date of program, service, or activity.
37. 10. If the request is for a curb, ramp or sidewalk, please list the nearest intersecting street.
39. 11. Specify the reason(s) you are requesting an accommodation (select all that apply):

    1. To provide full access to the facilities
    2. Other
41. 12. Describe the specific accommodation(s) you are requesting: *
43. 13. Describe how this will assist you:
45. Online Submission Notification All requests submitted online are sent directly to the City of Wichita Falls ADA Coordinator for action. The City will provide written acknowledgment of your request within 10 days. A written response to your request will be provided no later than 21 days from receipt of the request.
47. To receive a copy of your submission, please fill out your email address below and submit.
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field