Fillable LUIS Form (Liberty University)

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LUIS Form (Liberty University)

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File type: PDF

U.S.A. forms for Liberty University

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Interpreter Request Form
Location of Services Being Requested
Liberty Residential Campus
Lynchburg, VA
Virginia
Out of State (non-Virginia)
Requestor
_____________________________________
Name
Are you making this request for yourself or on the behalf
of another individual?
_____________________________________
Email
_____________________________________
Phone Number
If you are requesting for another individual, please provide
the name and contact information for that person:
____________________________
I am a:
Liberty Residential Student
Liberty Residential Faculty/Staff
Liberty University Online Student
Liberty University Online Faculty/Staff
State/Government Employee
Other
Services Requested
____________________________________________ _____________________ _____________________
Date Start Time End Time
__________________________________________________________________________________________
Type of Event
__________________________________________________________________________________________
Details of Event
__________________________________________________________________________________________
Location / Address of Event
________________________________
Deaf / H.H. Person Gender Will he or she be presenting?
________________________________
Deaf / H.H. Person Gender Will he or she be presenting?
________________________________
Deaf / H.H. Person Gender Will he or she be presenting?
________________________________
Hearing Person Gender Will he or she be presenting?
________________________________
Hearing Person Gender Will he or she be presenting?
________________________________
Hearing Person Gender Will he or she be presenting?
On-site Contact Person
________________________________ ________________________________
Name Phone Number
Other Services Requested
FM Unit
Volunteer Note Taker
Billing Information
_____________________________________ _____________________________________
Name Email
_____________________________________ ____________________ ___________ _________
Address City State Zip Code
Preferred Mode of Billing
Terms and Conditions
Liberty University is an educational facility in which students are training for excellence in Sign Language
interpreting.
I give permission for an interpreting student to observe and/or interpret for this assignment under
supervision of a qualified interpreter. I understand that I am responsible informing all parties involved.
I would prefer not to have an interpreting student actively interpret at this event, but I give my permission
for student observation.
I would prefer not to have an interpreting student actively interpret or observe at this event.
I give the Coordinator of Deaf and Hard of Hearing services permission to communicate about my case
with the professors, teaching assistants, interpreters, note-takers, and others directly involved with the
courses for which I have requested services.
_______________________________________ ______________________________
Signature Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Office Use Only
R U F/S B F/C P C
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LUIS Form (Liberty University)

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Completed 20 July 2020

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