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Online Request Form - Disability Accommodation

Two easy steps to register
Welcome to the Division of Extension's disability accommodation request process. Thank you for taking the time to share information on your accommodation request. Please know that all personal information below is considered confidential and will be treated as such. Completing the online request form allows for all information to be securely stored. Please fill in this form as completely as possible. Additionally, please note that this form automatically times out in 20 minutes.

If you need: more than 20 minutes, to look up information, or to type longer responses, we encourage that you type your responses in a separate document that you can save and then copy/paste your responses into this form. You will know that your request was submitted successfully if you get a screen that says "Application Submitted" (with a green check mark). This will be followed in a couple minutes by an automated email confirmation.

If you, or your child, are already registered and approved for accommodations for Division of Extension programs, and you have a new request, please email: disabilityaccesss@extension.wisc.edu to make updated accommodation requests for a new program, event, or media. You do not need to complete this form.
Personal Information
  1. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
  3. Hint: If the participant is a minor, please provide parent/guardian email.
Permanent Address
  1. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  1. Primary Disabilities/Conditions *

    Autism Spectrum (AUT)

    Emotional Behavioral Disability/Psychological Disability (PSY)

    Health Condition (HEL)

    Hearing Disability - Deaf/Hard of Hearing (HEA)

    Mobility/Physical Disability (MOB)

    Other Disabilities (OTH)

    Other Health Impairment: ADD/ADHD (ADD)

    Specific Learning Disability (LEA)

    Speech and Language (SLI)

    Temporary Disability (TEM)

    Traumatic Brain Injury (BRA)

    Undiagnosed (UND)

    Visual Disability - Blind/Low Vision (VIS)

Questions
  1. For whom are you requesting an accommodation? *
  2. Are you requesting any of the following accommodations? (check all that apply)
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