ADA Complaint Form

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First Name *

Last Name *

Phone Number

Are You Submitting This on Behalf of Someone Else? *

Yes

Personal Information

If the ADA complaint form is being submitted for someone other than yourself, please name that individual and provide their contact information

First Name *

Last Name *

Phone Number

Your Relationship to This Person *

Alleged Incident *

Describe the circumstances and location of this incident. Please be specific as possible (program, service, location, etc.) and provide as many details as possible.

Future Accommodations

Please describe an accommodation or accessibility improvement that the City of Waupun could implement to help provide greater access to this program or facility.

Proposed Changes *

What specific resolution are you requesting for the circumstances or specific location that prompted this complaint?

ADA Complaint Form

Contact Information

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