Learning Disabilities - Signature Sheet
{Insert Name of Program}
Americans with Disabilities Act
SIGNATURE SHEET
By signing below, I acknowledge that I have either read or had explained to me the Notice Under the Americans with Disabilities Act and the Grievance Procedure.
I understand that I may have a copy of the Notice under the Americans with Disabilities Act if I want one.
I understand that if I have questions, concerns or complaints I should contact the {Insert Name of Person coordinating ADA complaints}, at {Insert telephone number}.
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Signature of Service Recipient
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Print Name
of Service Recipient
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Date
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Witness