Accommodation Request Form

Ampact is committed to the full inclusion of all qualified individuals. As part of this commitment, we will ensure that persons with disabilities or persons needing a religious accommodation are provided reasonable accommodations. An accommodation is a modification or adjustment to a job application, interview process, job duties or the work environment to allow an individual to perform the essential functions of the position.

This form will be used as an initial review for your accommodation request. This is an interactive process to ensure the needs of members, sites, and employees of the organization are considered.  In some cases, we may need to consult additional individuals in the process such as site staff. Information will only be shared that is pertinent to reviewing and assessing the request. For the full Disability Accommodtions Policy, please click here.

Please complete the information below to the best of your knowledge.  After submitting this request, it will be reviewed by our Accommodations Coordinator who will reach out for additional information or to follow-up.

If you need assistance completing this form, please contact

Section 1: General Information

If you are completing this form on someone else's behalf, please fill out the remaining questions with that individual's information rather than your own.
Current Role *
Is this request needed in the next 7 days? *

Section 2: Request Information

Please check here if you have submitted an accommodation request to our organization during a previous application process or while serving in a different role. The request details below will be made optional and we will reference your previous submission.
Do you have a disability? A disability is a physical or mental impairment that substantially limits one or more major life activities? *
If you would prefer to discuss your request over the phone rather than completing the rest of the form, please indicate here.
Anticipated length of time the accommodation is needed *
Where do you anticipate needing this accommodation? (Check all that apply) *

If you do not require an accommodation, you do not need to submit this form. Please close this window or tab to cancel this request.

Section 3: Acknowledgement

I acknowledge the above information may be shared with staff or partners as necessary to consider or implement the accommodation.   *
Powered byFormsite
Ampact is a national organization that demonstrates the power of national service to solve complex social problems. We create innovative programs that focus on education, environmental stewardship, and healthy futures for communities. These programs include Reading Corps, Math Corps, Early Learning Corps, Climate Impact Corps, Recovery Corps and Heading Home Corps.