Hidden Disability Form
The Hidden Disability Sunflower program is a way for someone to self-disclose that they have a hidden disability and may need extra assistance. By wearing the Sunflower, you are letting people know that you might need extra help, understanding or just more time. Sunflower products are available to Lexington residents and members of the Lexington Community Center for use at the Community Center.
Who are you completing this form for?
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Myself
Someone else
Your name
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First Name
Last Name
Please chose the appropriate response(s)
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I am a Lexington resident
I have a Community Center membership
I am not a resident or a member of the Community Center
Address
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Their Name
*
First Name
Last Name
Please chose the appropriate response(s)
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They are a Lexington resident
They have a Community Center membership
They are not a resident or a member of the Community Center
Their Address
*
Your relationship
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Caregiver / Parent
Child
Friend
Other
What sunflower product would you like? - The products help tell others you have a hidden disability and may need extra assistance
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A lanyard (child)
A lanyard (adult)
A bracelet (fabric)
A bracelet (silicone child)
A bracelet (silicone adult)
A pin
An ID card
Would you like any of the following sticker icons to add to your ID card:
I have accessibility needs
I may need more time
I cannot stand for long periods of time
I may need a place to sit down and rest
Stairs / ramps are a barrier to me
I may need urgent access to the closest toilet facility
I have a caretaker / personal care assistant
I have an assistance dog
Please give me space
I need a quiet / safe place
I am sensitive to sound
I am sensitive to light
I am sensitive to smell
I am sensitive to smoke
Do not touch me
I have sight loss
I require large print
I use braille
I have hearing loss
I sign
I use assistive listening
I use audio description
I have a food allegy
How would you like to be contacted to pick up your Sunflower product when it is ready?
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Email
Phone
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Please allow for 7-10 business days for the form to be processed. You will be contacted when your sunflower products are ready for pick up at the Lexington Community Center.
Contact recdept@lexingtonma.gov with any questions
Submit
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