NOTE: This form is not HIPAA compliant, so please DO NOT share personal medical details. We only need to know what accommodation you are asking for, not why you may need it. If we need more information from you in our next conversation, we will ask you for it.

The YMCA of the North is committed to equity and improving access to our programs and spaces for all members, participants, and children in our care.

As a first step in our interactive accommodations process, please fill out the form below for yourself, your family member, or the person under your guardianship. The information you provide will help us to understand the specific details of the accommodation you are requesting for your time at the Y.  YMCA of the North teams will then collaborate with you and your family to determine what accommodations we may able to put in place and to provide a response guided by our core values if we are unable to accommodate part or all of your request.

Diabetes Medical Management Plan (DMMP)

If the accommodation is for a person with Diabetes, please also complete and provide a DMMP form to support our conversation and collaboration.

Name of the person requiring the accommodation

Name of person filling this out on behalf of the person (if applicable)

Contact information:

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