Patron Sign Language & Service Request Form

A form to request a sign language interpreter or related service for persons who are Deaf, Hard of Hearing (HOH), Deaf/Blind, non-verbal users, etc.

To request a sign language interpreter or related service for persons who are Deaf, Hard of Hearing (HOH), Deaf/Blind, non-verbal users, etc. Please complete and submit your request at least 2 weeks prior to the start of the program, activity or event. Authorized personnel with Disability Services will work to review and fulfill your request.

Request Information

Date of Request

Name of person making request

First Last

Name of person request is for (if different from requestor)

First Last

Contact Phone Number

Contact E-mail Address

Program/Activity/Event Information

Program/Activity/Event Name

Type of program/activity/event

(ie. class/program/event, theatrical performance, public forum, festival, drive thru, etc.)

Program/Activity/Event Location

Street Address Facilty/Park Indoors/Outdoors/Virtual

Type of Services Requested(Required)

Other

Program/Activity/Event Date(Required)

(ie. Friday, July 13th)

Program/Activity/Event Start and End Time(Required)

(ie. 1 pm-4:30 pm)

Program/Activity/Event Information Day of Logistics

(to be completed by program staff)

On-Site MAIN Contact Name

First Last

On-Site MAIN Contact Number

On-Site ALTERNATE Name & Contact Number

Where should the interpreter park?

Is a parking pass required?

Yes

Where should the interpreter sign-in and sign-out?

Inclement weather notifications and procedures.

For use by Program Access staff only

Date request received

Request to Contractor Made

Request Confirmed by Contractor

Interpreter(s) Information

for use by Program Access Staff only

Name of Interpreter

First Last

Interpreter E-mail address

Interpreter Phone Number

Name of Interpreter

First Last

Interpreter E-mail Address

Interpreter Phone Number

Other notes

for use by Program Access Staff only