Sign Language Interpreter Request Form
In accordance with the Americans with Disabilities Act Amendments Act of 2008, Chesterfield County Public Schools is required to, upon request, provide a Sign Language Interpreter when necessary for effective communication for a student, faculty, staff, family member or community stakeholder who is attending school division and school sponsored events.

This form should be completed by the School or Department requesting the services of a sign language interpreter.  This form may also be completed by a student, faculty, staff, family member or community stakeholder when appropriate.

Requests for an interpreter must be submitted at least five business days prior to the date services are needed. Requests submitted after noon are not counted as a business day; the day of service is not included in count. Coverage is not guaranteed for requests submitted less than five business days.

Upon completion of this form, you will receive an email summarizing the request.  Please review the information for accuracy.  Please email aslrequest@ccpsnet.net any corrections that need to be made.  

Completion of this form does not secure interpreting services. The requestor will be contacted by a CCPS designee via aslrequest@ccpsnet.net when coverage is secured.

For recurring events, this form must be completed for each event date (ex. An interpreter is needed for Chess club that meets once a month.  The Sign Language Interpreter request form must be submitted for each monthly meeting).



Email *
REQUESTOR INFORMATION
Requestor First Name *
Name of person submitting the request. 
Requestor Last Name *
Name of person submitting the request. 
Requestor Phone Number *
Phone number of person submitting the request. 
Requestor Email *
Email address of person submitting the request. 
Requestor School/Dept *
If the requestor is not a school division employee, please select the last option, "NON-CCPS"
EVENT INFORMATION
Date of Event *
MM
/
DD
/
YYYY
Recurring Event *
Is this a recurring event?

IMPORTANT:  For recurring events, this form must be completed for each event date (ex. An interpreter is needed for Chess Club that meets once a month.  The Sign Language Interpreter request form must be submitted for each monthly meeting.)
Virtual or In Person *
Location of Event *
Please select the school division site where the event will take place.  For off-site events, select other and type in the location.
Address of Event *
Please provide the address for off-site events.  
Please provide the meeting link for virtual events.
Start Time of Event *
Time
:
Length of Event *
Based on hours in 15 minute increments.  Please round up.
Type of Event *
Description of Event *
Please include any additional details about the event such as parking information, room number, on-site contact, etc.  
Individual Needing Interpreting Services Information
Information about the individual(s) needing sign language interpreting services.  If more than one individual needs interpreting services at the event, provide the additional names.
The individual is a: *
Individual 1 First Name *
Individual 1 Last Name *
Individual 2 First Name
Individual 2 Last Name
Individual 3 First Name
Individual 3 Last Name
Individual 4 First Name
Individual 4 Last Name
Individual 5 First Name
Individual 5 Last Name
Additional Information 
Please feel free to provide any additional information pertinent to the request.
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