Accommodation Requests

Contact Information

First Name*

Last Name*

Parent Name (if under 18)

Phone Number*

E-mail Address*

Participation

Activity or activities that you would like to participate in (check all the apply):*

Swim Lessons
Recreational Swimming
Strength & Conditioning
Fitness Assessment
Personal Training
Group Fitness
Small Group Training
Massage Therapy
Boating
Climbing Wall
Disc Golf
Sailing
Challenge Course
Open Recreation
Other (please list):

Location*
Date Requested*

Time Requested*

Duration of Activities*

Accommodations Used*

I use a wheelchair
I am hearing impaired, but I wear a hearing aid
I am hearing impaired and I do not wear a hearing aid
I rely on sign-language interpreting services
I use assistive mobility devices other than a wheelchair (crutches, brace, cane, prosthetics)
I need to read lips
I am visually impaired
I have difficulty walking up/down stairs
Other (please list):

Personal Assistant Information

I will be bringing a personal assistant*


Personal Assistant's Name

My personal assisant has a Gator 1 Card


Personal Assistant's Phone Number

Personal Assistant's Email Address

Gator Recre-Aider

I would like the assistance of a Gator Recre-Aider
Preference in Gender

How independent do you feel in using the facilities and programs?*

These activities can include accessing and exiting the facilities, participation in programs, and participation in cardio and weight equipment.

5. Completely comfortable using without accommodation support.
4. Could utilize fairly effectively without accommodation support.
3. Could utilize, but not as effectively as I could with accommodation support.
2. Could utilize few areas without accommodation support.
1. Could not utilize without accommodation support.

Special Needs or Requests