WDA-Americas Access Accommodation Request Form
WDA-Americas aspires to provide attendees with disabilities appropriate accommodations in order to provide equal access to Assembly event opportunities. If any attendee needs special accommodations related to a disability, please complete the below information. A WDA-Americas representative will follow-up with you after discussing access possibilities with the hosting institution. Confidentiality will be strictly maintained at all times.

Personal Information
Full Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Address *
Your answer
City/State/Zip/Country *
Your answer
Telephone *
Your answer
Email
Your answer
Emergency Contact Information
Full Name *
Your answer
Relationship *
Your answer
Telephone *
Your answer
Complete Address *
Your answer
Email *
Your answer
Support Questions
Have you been diagnosed as having a disability? *
If yes, when?
Your answer
Describe disability, including symptoms *
Your answer
Are you taking any medication for the disability? *
If so, please provide the name(s) of the medications, how much is taken, and how frequently.
Your answer
What accommodations are you requesting to equalize your opportunities at the WDA-Americas Assembly events? *
Your answer
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