PENNSIC WAR 37 Disability Services Request

Disability Services Request Form

Please complete this form if you are requesting Disability Services.

Contact the Disability Services Coordinator if you have any questions.

About You

Modern Name:	SCA Name:
Address:
Phone number:	Email:
Do you have a disability? Yes No

Services Requested


Recharging services
Do you have a scooter or other medically-required device that requires recharging?	Yes No
Preferred time to recharge	Describe the item/device
Handicapped Parking
Do you need a space in Handicapped Parking ?	Yes No

Service/Assistance Animals
Are you bringing a service animal?	Yes No
Service animal's name
Port-a-john request
Are you requesting placement of a port-a-john?	Yes No
(This is only a request; we cannot guarantee port-a-john placement.)
Reason for request
What location are you requesting (be specific):
Other Questions or Comments

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