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Request for Interpreter / Captioner

To Students,

Classroom Services will make every attempt to fulfill your request and will inform you about its status. If this request cannot be fulfilled, Classroom Services will find other ways to help you (reschedule an appointment, for example). Completing this form is not a guarantee that you will receive services. In order to process your request, Classroom Services must receive it at least four business days in advance.


NOTE: Items with an asterisk (*) are required.
Student Information
  Today's Date7/5/2008
*Student ID:
*Name:
*Email Address:
Phone Number:
Nature of Event:

If appointment or other,
Event Details
*Do you want interpreters or captioners for this event? Interpreters Captioners
*Is the event one-time or ongoing?
(for example, every week) 		One-time Ongoing
If the event is ongoing, please tell us when it will happen and include the end date:
*Start Date of the Event: ,
*End Date of the Event: ,
*Start Time of Event:
*End Time of Event:
*Event Location: On-Campus  Off-Campus

If On-Campus:


If Off-Campus:
*Instructor/
Staff Member/
Event Coordinator Name:
Your preferences for interpreters or captioners (Optional)
1:
2:
3: