Disability Services Request
Please complete and submit this form by June 9 to request Disability Services.

Contact the Disability Services Coordinator (disability@pennsicwar.org) if you have any questions.

Contact Info
Modern Name *
Your answer
SCA Name
Your answer
Email Address *
Your answer
Cell Phone Number *
Your answer
Arrival Date *
MM
/
DD
/
YYYY
Recharging Services
Recharging Request
Will you need to recharge a scooter or battery for a medically-required device?
Recharging Request
Will you need to recharge a scooter or battery for a medically-required device?
Device Type
Please enter a description of your device
Your answer
Timeslot
Your preferred time to recharge:
Charging Station
The location you prefer to use:
Frequency
How often will you need to recharge?
Your answer
PortaJohn Requests
This is only a request; we cannot guarantee port-a-john placement
Are you requesting placement of a port-a-john?
Placement
Where are you requesting that it be placed? Be specific: camp name / block number / road intersection
Your answer
Reason for Request
Your answer
Other Questions or Comments
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service