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6. Livonia Parks & Recreation strives to ensure quality programs and services to individuals with disabilities. This form enables us to make appropriate accommodations when requested. Please note that the accommodation requests are considered on an individual basis and determined by the needs of the individuals and the program they are participating in. Increasing the staff-to-participant ratio is not guaranteed and depends on resident status, availability, and the specific needs of the individuals. (Those who are not Livonia residents are welcome to participate in our programs, yet additional staff will not be provided.  

   If you do not receive an email response after you have completed this form, please contact mkoppin@livonia.gov 

   * Please Note: A new request must be made for each program you are registered for. Please fill in the required information for each and every program request. If the information is invalid or incomplete, your request may be delayed. 

8. First Name of Person Completing this Form
9. Last Name of Person Completing this Form
10. Cell Phone Number
12. Email Address
14. First Name of Participant
15. Last Name of Participant
17. Age
18. Gender

    1. Male
    2. Female
    3. Choose not to disclose
19. Additional Phone Number (Home/Work)
21. Home Address
22. Season of Program you've Registered For

    1. Winter
    2. Spring
    3. Summer
    4. Fall
24. Name of Program
25. Program Location
27. Program Dates and Times
    Program Dates and Times Start Date

    Program Dates and Times Start Time

    —

    Program Dates and Times End Date

    Program Dates and Times End Time
28. Days of the Week Program Runs

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday

    1. Friday
    2. Saturday
    3. Sunday
30. Accommodation Being Requested

    1. Increase Staff to Participant Ratio
    2. Sign-Language Interpreter
    3. Bring own support (register as volunteer)

    1. Adaptive Equipment
    2. Facility Accessibility
    3. Large Print or Braille

    1. Disability Training for Staff
    2. Other
32. Additional Information for Accommodation Being Requested
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field