Accommodation Request Form

Thinking of attending a program but not sure if you will be comfortable? Or have you attended a program but needed something that wasn’t available? Please fill out our request form!

We will consider and respond to all requests as soon as possible and provide accommodations as far as reasonably possible. Requests must be made 7 business days before the program or event start date.

If you need help filling out this form, phone 604-485-4796 or contact desk@prpl.ca and use the subject line Accommodation Request. Completed forms can be submitted electronically or printed and returned to 100-6975 Alberni Street Powell River V8A 2B8 in person or by mail. Or, if you would prefer to make your request without using this form, simply phone, email, or come in to the Library.

Personal information

Is this request for

Yourself

Someone else

Your name

First Last

Pronouns

Your phone

Your email

Name of person who requires the accommodation(Required)

First Last

Pronouns

Phone(Required)

Email(Required)

Age range

up to 9 years

10-15 years

15-19 years

Adult

Will the person requiring the accommodation attend with a caregiver or other person?(Required)

Yes

Companion Name

First Last

Pronouns

Please name the service, program, or event at which you need accommodation:(Required)

Date(Required)

Month

Day

Year

Time(Required)

Hours

Minutes

AM/PM

Type of accommodation(s) being requested

What accommodations are you requesting? Please check all that apply and provide more details when prompted.(Required)

Program or event information in an accessible reading format

Physical access

Event captioning (speaker's words displayed in print on screen)

Other - please describe

Program or event information in accessible reading format(Required)

Large Print

Audio Format - MP3 (or other, please describe below)

Electronic format (please describe below)

Other (please describe below)

Please tell us more about your required accessible reading format

Physical access(Required)

Reserved seating

Rest area for service dog

Noise-cancelling headphones

Other (please describe below)

Please tell us more about your physical access needs(Required)

Other - Please describe your accommodation request(Required)

We use your feedback to improve our services. Additional feedback:

Unfortunately, due to a local lack of American Sign Language interpreters, we are currently unable to provide ASL interpretation by request. We do provide selected programming with ASL, such as ASL Kids Club.

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