Accessibility Request Form

NEIGHBORWORKS TRAINING REASONABLE ACCOMMODATIONS ACCESSIBILITY REQUEST FORM

In this form we are collecting your specific accessibility request details in order to address the accommodation.
If you prefer to talk with one of our team members prior to submitting this form, we can be reached at nti@nw.org or 1-800-438-5547. You can expect confidential and prompt follow-up on your request.

Please note that the purchase and/or rental of mobility devices and/or other medical equipment is the responsibility of the event attendee.

1. What in person event or online course are you attending? *This question is required.

2. Contact Details *This question is required.

First Name

Last Name

Company Name

State

Email Address

Best Phone # To Reach You

Alternate Phone

3. What categories best describe your reasonable accommodation request? You may select more than one category. *This question is required.

4. MOBILITY: Please provide a detailed description of your mobility accessibility request. To help guide you, below are some descriptive questions we find helpful so we can best support your accommodation needs.

Will you be using a wheelchair, scooter, walker, or other device? Do you require an extension cord to plug in your device during the course day?
If using a mobility device, do you prefer to park the device and walk to ADA seating or do you require roll-up seating?
If we are covering your lodging, do you require a roll-in/walk-in shower room, or have other specific room requirements?
Are you able to ascend or descend a bus shuttle steps? (some events or site visit courses have shuttle bus usage)

4. VISION: Please provide a detailed description of your vision accessibility request. To help guide you, below are some descriptive questions we find helpful so we can best support your accommodation needs.

Do you require access to electronic materials in advance? If yes, please specify the type of device and/or software you will be using to e-read or review the materials.
Will you be bringing a personal device to review electronic materials in the course and do you require power plug-in access?
For in person events, will you be bringing a guide dog with you?
For in person events, will you be bringing a companion/aide/guide to assist you at the event and will that person require reserved seating next to you at your registered activities?
Do you require preferential seating (front of room etc.), please specify your need?

4. HEARING: Please provide a detailed description of your hearing accessibility request. To help guide you, below are some descriptive questions we find helpful so we can best support your accommodation needs.

Do you require preferential seating near the presenter or near a speaker system?
For large ballroom plenaries,do you require a headset?
Will you be bringing someone to perform ASL interpretation for you at your event activities?
Are you requesting the event to provide ASL interpretation for you?

4. DIETARY: Please provide a detailed description of your dietary accessibility request. To help guide you, below are some descriptive questions we find helpful so we can best support your accommodation needs.

Do you have an anaphylactic, life threatening food allergy? To what specific food?
Can you be around that food as long as you have alternate, safe options for you to select from?
Do you have a religious dietary requirement? (e.g.: Halal, Kosher) For Halal, is a vegetarian meal an alternate option for you?
For group meals, please specify vegan, vegetarian, gluten free, etc.

4. NEURODIVERSITY: Please provide a detailed description of your neurodiverse accessibility request. To help guide you, below are some descriptive questions we find helpful so we can best support your accommodation needs.

Do you require preferential seating? What does that look like for you? (e.g., up front, near an exit, to the side, etc.)
Do you require electronic materials in advance?
Do you require additional assistance from our team to review the design/flow of the course and what will happen in your course experience to help you visualize and understand what a course day looks like?
Do you require a sensory space or tool kit?
Do you require testing accommodations?

4. OTHER: Please provide a detailed description of the OTHER reasonable accessibility accommodations you are requesting. What does implementation of the accommodation look like for you to access your learning?