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Interpreter Request Form
 

Last Name:         First Name:

Contact Number:

Email Address:

 

I am requesting an interpreter for:

Course/Event Date/Day Time Room/Building Department Contact Person
& Phone Number

Additional Comments:

This request form does not guarantee an interpreter can be provided.  It must be filled out completely and submitted at least 72 hours prior to an assignment in order for your application to be processed.  The earlier you submit the request, the better the chances are of securing an interpreter. 

   I have read and understand the above, and know this request MUST be approved by Student Disability Services upon submission. 

Office Use Only Approved      Denied
 
Interpreter Accepting Assignment: _____________________________________________________________________________________
 
__________________________________________________________________________________________________________________
Interpreter Coordinator Date