ADA Accommodation Request Form
For the Eugene Family YMCA
Applicant Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
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?
Yes
No
What were the past accommodations, and how effective were they?
Please upload any related supporting documentation.
Browse Files
Cancel
of
Applicant Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: