Wufoo

Interpreter Request Form

Please complete the following information to begin the process of requesting Sign Language Interpreter(s)/Transcribers/Captionists. If this is the first request a signed contract is required, this will come via e-mail.

Name * First Last
Company Name
Email
Phone * - (###) - ### ####
Fax - (###) - ### ####
Billing Address (New Clients Only)

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Mailing Address where correspondence regarding this assignment may be delivered to.
Payment Method
Current client of ICSDeaf: Yes, and I've read and understood the Terms and Conditions (T&C) of ICSDeaf that my Company has authorized/signed. Furthermore, those T&C apply.

Review Terms and Condition!
About the Deaf/Hard of Hearing Client(s)
Deaf/Hard of Hearing Client's Name First Last
Language Preference(s)

Provide this information if known.
* Additional fees may apply (Tactile and Trilingual)
Other Details:
About the Assignment
Status

What to Fill Out:
-New Request: Entire Form
-Modification: New assignment information (add old assignment reference information under "comments/information")
Setting

This helps ICSDeaf best match Interpreters with experience in the setting, as well as, help interpreters prepare.
Check as Applies to this request: Technical Vocabulary Employee Termination Legal Situation Mental Health Pregnancy Termination (Abortion) Emotionally Charged Contents Open wounds/Visible blood Violence/Offensive Behavior
Number of Interpreter(s)/Captionist(s)*

*Each interpreter/captionist is charged separately.
(Assignments going OVER TWO (2) HOURS or more demanding [i.e. technical, legal, etc.] will require a team of interpreters. Please consult with our staff to assess your event's needs.)
Specific Associate Request: First Last
Preference of Associate (Interpreter/Captionist) to attend and provide services (This can't be guaranteed but will be attempted.)
Accommodation Preferred
On-site Contact First Last
Person whom the Interpreter may contact while going or at the assignment. This may include the Deaf/Hard of Hearing person's contact information too.
On-site Phone - (###) - ### ####
Phone number of person on-site whom the Interpreter may contact while going or at the assignment. (Be sure to include a number where Interpreter may reach this person the date of the assignment).
Date of Assignment / MM / DD YYYY
(Start Date - if reoccurring)
End Date (if Reoccuring) / MM / DD YYYY
Start Time : HH : MM SS AM/PM
End Time* : HH : MM SS AM/PM
*Assignment going over two (2) hours will require a team of interpreters.
Assignment reoccurs: WEEKLY BI-WEEKLY Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Event Title

Include: Conference Title, Course Title/Code , Doctor Visit (i.e. Check Up, Emergency Room, etc.), Docket/Case Title: Smith Vs. Brown.
Assignment Location (Name)

Name of Location. (Example: Branch Name, Patriots High School (Campus & Building Name/Number), Central County Court, Concert Venue, etc.)
Assignment Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Additional Information
Event Program/Agenda

Please upload any DOC or PDF Program or Agenda pertaining to the event.
Comments/Information

Include Assignment's: Directions to the Location, Reoccurring Dates/Times, Deaf/Hard of Hearing Clients names and Signing preferences. Specify if there is the need for Tactile Interpreting (Deaf-Blind), Trilingual, or any others.
How did you hear about ICSDeaf?
Referral/Other:

How did you find us?
Do Not Fill This Out

Wufoo

Interpreter Request Form

About the Deaf/Hard of Hearing Client(s)

About the Assignment

Additional Information