City of Scottsdale

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Adaptive Services Information Form

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Personal Information Participant's Name: Date of Birth: (MM/MM/YYYY) Age/Grade: Gender: Male Female Disability: Address: City: Zip: Phone:  Enter a valid phone number. Example: 123-456-7890 Email:  Enter a valid email address. Example: name@company.com Parent/Guardian's Name: Address: (if different than above) City: Zip: Parent/Guardian's Name: Address: (if different than above) City: Zip: Emergency Contacts Name: Relationship: Home Phone:  Enter a valid phone number. Example: 123-456-7890 Cell Phone:  Enter a valid phone number. Example: 123-456-7890 Name: Relationship: Home Phone:  Enter a valid phone number. Example: 123-456-7890 Cell Phone:  Enter a valid phone number. Example: 123-456-7890

Contact Information

Adaptive Services Center
8102 E. Jackrabbit Road
Scottsdale, AZ 85250
P: 480-312-2234
AdaptiveServices@ScottsdaleAZ.gov

TTY/TDD Users
For TTY Users - Arizona Relay Service (1-800-367-8939) may contact the Adaptive Services Office at 480-312-2234.

Reasonable Accommodations
Persons with a disability may request a reasonable accommodation for access to all Adaptive Services programs by emailing AdaptiveServices@ScottsdaleAZ.gov

Making a Difference

Hear how Adaptive Services is improving lives:

 

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