ADA Accommodation Request

The Town of Ashland prohibits discrimination against individuals with disabilities in its services, programs, and activities.

If you require a reasonable accommodation to access a Town of Ashland service, program, or activity, you may request such accommodation in one of several ways:

1. Complete the online form below.

2. Complete the ADA Accommodation Request fillable PDF, save it to your computer, and email it to wcornwell@ashlandva.gov.

3. Contact the specific Town department directly.

If you need assistance with submitting your accommodation request, please contact the Town's ADA Coordinator at wcornwell@ashlandva.gov or call (804) 629-0888.

To reach the Town of Ashland Police Department's ADA liaison, please contact Officer Chip Watts at cwatts@ashlandpolice.us or call (804) 412-0615.

ADA Accommodation Request Form

What type of accommodation are you requesting?*
1. Service or Program
2. Facility Accessibility
3. Communications
4. Employment
5. Other
If you selected other above, please explain:
Contact Information of Individual Needing Accommodation
First Name*
Last Name*
Home Phone Number*
Cell Phone Number
Email Address*
Address1
Address2*
City*
State*
Zip*
Contact Information of Requesting Individual, if different.
First Name
Last Name
Home Phone Number
Cell Phone Number
Email Address
Address1
Address2
City
State
Zip
Detailed Information about Request:
Date Accommodation is Needed*
Date Accommodation is Needed
Location Where Accommodation is Needed*
Describe Accommodation Request*
Include Any Additional Comments*

Leave This Blank:

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

This field is not part of the form submission.
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ADA Accommodation Request

ADA Accommodation Request Form

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