Application Form
New England ADA Center Field Based Training Day for Cities and Towns 2014
Please complete this application form and email to: Oce Harrison, Project Director, New
England ADA Center - [email protected] by 5:00 PM Tuesday, December
31, 2014
Date
Name of person completing this form and contact information:
Name
Title
Name of municipality
Address
Phone
Fax
Email
Facility to be studied:
Facility Name
Facility Address
Facility Website
www.NewEnglandADA.org • 800-949-4232 • 200 Portland Street, Boston MA 02114
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Type of facility to be studied:
Please describe type of facility (e.g. a Town Hall, library, school building, central pedestrian area, senior center,
park, playground, health department, police station, playing field, recreation site, or other municipal facilities).
Facility Type ______________________________________
Describe the facility, including accessibility issues, how one arrives there (public
transportation, automobile), who uses the facilities and for what purpose.
Enter text here:
Provide a description of the meeting space. The meeting space must be accessible and within
the facility or within walking distance of the facility to be studied.
Enter text here:
Attach up to 4 digital photos of the proposed facility. Be sure to compress your pictures to no
larger than 250 kilobytes JPEG or PNG. Color images are preferred.
Attach a floor plan and site plan of the proposed facility on the next page. (Preferred but not
required – can be fairly rough)
www.NewEnglandADA.org • 800-949-4232 • 200 Portland Street, Boston MA 02114
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Permissions and Agreements
Permission to photograph or videotape the facility to be studied:
__________________________________
training purposes (name of person).
agrees to have the site photographed for
Agrees to designate a note taker for the training day:
__________________________________
note taker for the day.
(name of person) agrees to designate a
Agrees to promote on-line registration of participants:
___________________________________ (name of person) agree to promote on-line
registration of training participants.
Agrees to follow up with State Affiliate at a mutually agreed upon time and date:
___________________________________ (name of person) agrees to follow-up with the
Mass Office on Disability at a mutually agreed upon time and date.
Signature
Date
____________________________________
________________________
www.NewEnglandADA.org
800-949-4232
200 Portland Street
Boston MA 02114
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