TR Request

Request for Program Modification

Richmond Parks, Recreation, and Community Facilities offers inclusion support to individuals who request a modification based on the Americans with Disabilities Act (ADA) to participate in an activity, program, or service. Individuals who wish to request a modification should complete and submit this form. Requests should be made for each program.

Participant Name *

Submitter First Name *

Submitter Last Name *

Email *

Phone Number *

Preferred method of contact: *

Has this individual participated in a PRCF (Parks and Rec) program before? *

Has this individual received inclusion support from PRCF before? *

Program Name and Location (example: Bellemeade After School Program) *

Program Start Date *

Please describe the specific modification you are requesting: *

What is participant's disability? (optional)

Please describe how the modification will assist the participant: *

Please share any safety or behavior concerns for the participant in this specific program: *

If participant is still in school, what type of classroom is child in? (i.e. self-contained Exceptional Ed classroom, traditional classroom, etc).

The Therapeutic Recreation Office will follow-up on all requests as quickly as possible, but request to receive notification 2 weeks (or 10 business days) prior to the start date of the scheduled program or event. (Alternative formats are available upon request.) Additional forms will be required for our assessment process. Please contact Therapeutic Recreation staff at 804-646-6817 for more information.