ADA Accommodation Request Form 
This form is to request accommodations for programs offered by DJHCC. Please complete this form if you are enrolled in one of our programs & need accommodations. 

Please complete this form at minimum 10 days prior to the event you are requesting accommodation for. Please know that not all accommodations may be possible. Someone will follow up with you within 72 hours following submitting this form. 

Please email info@djhcc.org if you need more information.
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Full Name *
Date of Birth *
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Phone Number *
Email Address *
Mailing Address  *
Type of Disability 
Please describe your disability and how it impacts your participation in programs, services, or activities:
Type of Disability  *
Please, describe how the disability affects your ability to fully participate:
 *
Request Accommodations
Please describe the accommodation(s) you are requesting (e.g., sign language interpreter, wheelchair access, modified seating, extended time for activities, etc.):
Request Accommodations  *
Do you need this accommodation for specific programs or activities? (Please specify)
 *
If yes, What program(s) or event(s) are you requesting accommodations for?
Date(s) of Participation or Event(s):
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Prior Accommodations- Have you previously received accommodations from our center or other programs?
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If yes, please describe the accommodations you received and if they were sufficient: 
Emergency contact (Name, Relationship, Phone number)  *
Signature  *
Important Information
  • Confidentiality: All information provided in this form is confidential and used solely for the purpose of determining accommodations.
  • Reasonable Accommodation: Washington State and the ADA require that reasonable accommodations be provided unless doing so would cause undue hardship or fundamentally alter the nature of the program.
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