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2. Instructions:

   Please complete this form to request accommodations for Orange County government programs, services, events, or facilities. Requests should be submitted at least 48 hours in advance to ensure accommodations can be arranged.

   If you need assistance completing this form, contact:

   Email: civilrights@orangcountync.gov

   Phone: (919) 245-2594

4. Personal Information
6. Full Name*
8. Email Address
9. Phone Number
11. Preferred Contact Method

    1. Phone
    2. Email
    3. Other
12. If other, please share preferred contact method here
16. Are you submitting this request on behalf of someone else?*

    1. Yes
    2. No
17. If yes, what is your relationship to the individual?
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field