This study examined the performance, demographics, and contextual factors of students taking the ACT® test with accommodations compared to students taking the ACT without accommodations. We examined the prevalence of accommodations provided and disability categories as well as performance by disability type. We also examined demographic characteristics and high school experiences of students testing with and without accommodations. We found that students testing with accommodations had demographics similar to students testing without accommodations, but they were somewhat more likely to be male, White, from high or low-income families, and less likely to be female, Hispanic/Latino, Asian, or from middle-income families. Students testing with accommodations were less likely to take upper-level core academic courses in high school, but they expressed similar college aspirations as their peers who tested without accommodations. The most common accommodations were extra time or testing in a small group setting, and additional accommodations tended to be associated with specific disabilities. The most common disabilities were ADHD and learning disabilities, and a substantial proportion of students had multiple disabilities. Students who tested with accommodations tended to score somewhat lower on the ACT, but there was a large amount of variation in average performance by disability type, and demographic characteristics accounted for a substantial amount of variance in scores. Students with intellectual or conduct disorders tended to have the lowest scores, while students with anxiety or depression tended to have the highest scores. High school grades followed a similar pattern in that groups with higher average ACT scores tended to have higher grades. In general, correlations between ACT scores and high school grades were comparable for students who tested with and without accommodations, but again there was variability by disability type, with lower correlations for students with autism, intellectual disorders, math learning disabilities, and conduct disorders.