ADA Accommodation Request Form
For the Eugene Family YMCA
Street Address Line 2
State / Province
Postal / Zip Code
Which membership benefits, programs, services or facility areas are you having trouble accessing?
What limitation is interfering with your access to our facility areas, services, or programs?
Please indicate what type of accommodations you need.
Have you had any accommodations in the past for this same limitation?
What were the past accommodations, and how effective were they?
Please upload any related supporting documentation.
Should be Empty: