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Request for Reasonable Accommodation

  1. Request for Reasonable Accommodation
    Many accommodations are simple changes in procedures or one-on-one assistance to ensure that access is provided; curbside assistance, alternative format for communication, printing information in large font, etc. This form may be completed and returned directly to the Department providing the program or service so they may best serve you. The form may also be completed and returned to:
    St. Charles County Human Resources
    ADA Coordinator
    201 N. 2nd
    Room 519
    St. Charles, MO 63301
    For assistance in completing this form contact Human Resources, ADA Coordinator, at 636-949-7320, or email.
  2. 1. Choose the box which applies to you.
  3. 2. Reason for the Application
  4. (Applied for or Performing)
  5. 5d. Have you had an accommodation in the past for your limitation?
  6. Signature
    Checking this box serves as a signature.
  7. Employees Only
  8. Signature
    Checking this box serves as a signature.
  9. Leave This Blank:

  10. This field is not part of the form submission.