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Remote Participation Public Meetings Application

Remote Participation Public Meetings Application

Please fill out the form below to apply to participate remotely via electronic means at the St. Tammany Parish Government public meeting. pursuant: ACT 393: La. R.S. 42 14(E)

Application to Participate Remotely at Public Meetings

Date Field

Applicants Full Name*

Caregiver Full Name (If Applicable)

Applicants Address*

Caregiver Address

Applicant Contact Phone Number*

Caregiver Contact Phone Number

Applicant Email Address*

Caregiver Email Address

Meeting / Agenda Information

Name date and time of meeting you wish to attend remotely*

Agenda item or case number you wish to discuss*

Have you been diagnosed with a disiabilty recognized by the Americans with Disabilities Act?*

YES

Are you Currently diagnosed with this disability?*

YES

How does the functional limitation caused by your disability affect your ability to attend the public meeting?*

I certify that I am aware that submitting false or incomplete information on this form may subject me to penalties, including that I may be found ineligible to participate remotely in public meetings.

Applicant Signature*

Signature Date*

Caregiver Signature

Signature Date