DHCC Philadelphia School District ASL Request Form

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

A team member of the Philadelphia School District Translation and Interpretation Services must provide name, contact number & email.

Translation and Interpretation Services Requester Name

First name

Last name

Translation and Interpretation Services Email

Translation and Interpretation Services 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

Service Request Details

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.

Consumer Details

Deaf/Hard-of-Hearing Client Name

Name of individual needing interpretation services

First name

Last name

Consumer relation to School District

Student

Parent/Guardian

District Staff Member

Other

Names of Preferred Interpreter, if requested

DHCC Philadelphia School District ASL Request Form

Contact Details

Service Request Details

Consumer Details

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