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2. Date and Time
   Date and Time

   Date and Time
4. First Name*
5. Last Name*
7. Email Address*
9. Address1*
11. Address2
13. City
14. State
15. Zip
17. Primary Contact Number*
19. Alternate Phone Number (Optional)
21. Best Time To Call
23. Is this request for a minor child?
25. If yes, how old is the minor?
27. Type of Accommodation(s)*

    Please select all types of accommodation(s) that apply

    1. Mobility - Sidewalks
    2. Parking - Accessibility
    3. Programming - Leisure Services (i.e. access to recreation classes)
    4. Programming - General Government (i.e. access to public meetings)
    5. Access to Township Facilities
    6. Access to Township Materials or Data
    7. Auxiliary Aids or Services
    8. Canton Township Employee - Service Animal Registration
    9. Translation Services (Provide detail i.e. English to Arabic)
    10. Other (Please provide as much detail as possible)
29. Accommodation Description *
    Please describe the nature of the accommodation(s) being requested. Please provide as much detail as possible, including: specific location, meeting date and time, and class information.
33. Is your accommodation request time sensitive? *

    1. Yes
    2. No
35. The requester will be contacted within four business days by appropriate Canton Township staff.
    Canton Township will send email confirmation that your request has been received and is being reviewed within four business days of receiving your request. If you do not receive confirmation that Canton Township received your request for accommodation please contact Human Resources directly at 734-394-5260 to verify the request went through. Reasonable accommodations can be made with advance notice. Contact Human Resources directly at 734-394-5260 if the accommodation request is needed within four business days.
37. Legal Signature *

    I acknowledge that the information provided is accurate and complete.

    1. I agree
39. Requester's Electronic Signature
    Please type full name.
41. Canton Township ADA Contact Information

    Barb Brouillette, Interim ADA Compliance Coordinator, 1150 S. Canton Center Road, Canton, MI 48188, (734) 394-5260

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field