Request for Reasonable Accommodation

Date:Date

Name:Client first nameClient last name

I am a current resident of Into Action Sober Living? Radio buttons

Please let us know how the accommodation will help you to take part in our program and help you to meet other
requirements of our program. 

Do not include sensitive medical information about your disability on this form.

I request the following reasonable accommodation:

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I request the reasonable accommodation because:

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I understand that a reasonable accommodation request is a cooperative and interactive process between the operator and the resident/applicant, and that further information and documentation may be requested.  Into Action Sober Living will address each request in a timely manner.

Please notify owner/operator at info@intoaction.net once this form has been submitted.

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