We are committed to providing equal access to all programs, services, activities, and facilities. If we have fallen short, we apologize and appreciate you bringing your concern to our attention.

This form is used to file a complaint alleging discrimination on the basis of disability in the provision of programs, services, activities, or facilities operated by the Williston Parks & Recreation District (WPRD), in accordance with Title II of the Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973.

Any person who believes they have been subjected to discrimination on the basis of disability may file a written complaint within 180 calendar days of the alleged discriminatory act. Complaints may be submitted by the individual, or by a representative or caregiver on the individual’s behalf. Assistance in completing this form is available by contacting the ADA Coordinator listed below.

Upon receipt of a completed complaint form, the ADA Coordinator will contact the complainant within five (5) business days to acknowledge the complaint and discuss next steps in the resolution process.

Full Name: (required)

Address: (required)

City, State, Zip Code: (required)

Phone: (required)

Email: (required)

Preferred contact method: (required)

Phone

Email

Mail

Other

Please Specify: (required)

If you are filing on behalf of someone else, please provide the name of the individual on whose behalf you are filing:

Relationship:

Parent/Guardian

Caregiver

Representative

Other

Please Specify:

Date of the incident or concern: (required)

Location (Park/Facility/Program): (required)

Describe the accessibility issue or act of discrimination. Explain what happened, who was involved, and how you or others were affected. Attach additional pages or photographs if necessary. (required)

Upload any necessary documentation here:

Type of Issue (Check all that apply): (required)

Physical access barrier (ramp, doorway, restroom, pathway, parking)

Program access or participation barrier

Communication access (website, forms, signage)

Request for accommodation

Staff interaction or service issue

Other:

Please Specify:

Have you previously requested assistance or accommodation from WPRD staff?: (required)

Yes

No

Other

Please Specify:

What action or resolution would you like WPRD to take? (required)

Alternative format or assistance needed to communicate with you: (required)

Audio

Braille

Large Print

Language Translation

Relay Service

Other

Please Specify:

I affirm that the information provided is true to the best of my knowledge and belief:

Yes

No

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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