Participant Accommodation Request

Purpose: 

We want to make sure everyone can access and participate in PCRS services. Please use this form to tell us about any barriers you are experiencing and what may help. We will work with you to explore reasonable options and do our best to support your access and participation. You do not need to provide a diagnosis or medical information. Please only share what is needed for us to understand your request.

Related policy: 145.01 Accessibility Policy


If you need assistance ask a staff to help fill this out. Once submitted a person from the program you are participating in will get in touch with you.

1. Person making the request















2. Service, location, or activity




3. Barrier and accommodation requested

Describe what makes it difficult to access or participate. Do not include medical details unless they are necessary.

Examples may include an accessible format, interpretation, communication support, physical access change, scheduling adjustment, technology support, transportation support, or another reasonable option.

List any other options you would be comfortable considering.
5. Requester acknowledgement

I confirm that the information in this form is accurate to the best of my knowledge. I understand that PCRS may need to discuss the request with me to identify a reasonable accommodation. Information will be shared only as needed to review, arrange, and follow up on the request, subject to applicable PCRS privacy and records practices.



Contact Information