DHCC Philadelphia School District ASL Request Form

This interpreter request form is ONLY for Philadelphia School District customer use.

Assignment Task Number

Point of Contact:

First name

Last name

Point of Contact Email

Point of Contact Phone Number

Contact Details

Contact For Day of Services Name

First name

Last name

Contact For Day of Services Phone

Contact For Day of Services Email

Date of Service

Start Time

Time

HoursMinutes

End Time

Time

HoursMinutes

Location Type

In-Person

Remote/VRI

School or Building Name

Exact Service Location Address

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Additional Information

Email IRD@dhcc.org anything that may help the interpreter to be better prepared

Who will be attending the services requested?

Please provide a list of key individuals, including their names and titles.

Deaf/Hard-of-Hearing Client Name

Name of individual needing interpretation services

First name

Last name

Names of Preferred Interpreter, if requested