ATTACHMENT L

SAMPLE STATEMENTS FOR REGISTRATION FORMS

The registration form is an opportunity to obtain information about a participant's needs. The following are three examples of statements appropriate for registration forms:

SAMPLE 1

I am requesting the following auxiliary aids or services due to my disability: __________________________________________________.

I may be contacted at the following telephone number during day hours for more information: ____________________________.

SAMPLE 2

Auxiliary aids or services for individuals with disabilities (e.g., sign language interpreter, large print materials, taped materials, accessible parking) can be provided, if requested in advance. Please call (indicate telephone number V/TTY/TRS) by (indicate deadline date) and speak with (indicate name of a person) to discuss your needs.

March 2008                   Attachment L, Page 1
Disability and Communication Access Board

SAMPLE 3

Please indicate any auxiliary aid or service needed, due to disability, that would assist you in participating in the activity:

____ Audiocassette tape

____ Large print

____ Braille

____ Sign language interpreter

____ Amplification system, please specify _____________________________

____ Accessible parking

____ Accessible facility

____ Special diet, please specify _____________________________________

____ Mobility assistance, please specify _______________________________

____ Other, please specify

I may be contacted at the following telephone number for more information: ____________________________.

March 2008                 Attachment L, Page 2
Disability and Communication Access Board