This form is for faculty and staff of Cerritos College that need to request 
communication services for a deaf/hard-of-hearing person to participate in a
campus activity such as a counseling appointment, job interview, or class 
activity.  

Please fill out this form completely.  Each request must be filled-out separately 
(only one request per form).

Your Name:         

Your Email Address:

Telephone:

Please select  the appropriate service.

 Need service for a ONE-TIME assignment

 Need service for a new class for the semester

  Cancel service ONE-TIME (list reason below in the comments section)

  Cancel service for the whole semester (list reason below in comments section)

Please select the communication preference

  Sign Language Interpreter     

  Real-Time Captionist

  Assistive Listening Device

Please fill in ALL information in this section.

Please type in the class title or type of appointment: (Counseling, class etc.)   

Select the appropriate day service will be needed or canceled 

 Mon     Tue     Wed     Th    Fri     Sat     Sun

Date of class/appt.:   

Start Time:     AM    PM

End Time:      AM    PM

Location of class/appointment (building and room):

Name of student your class/appointment is with:

Comments/Additional Information:  Please provide a description of the class/appt
and include the name of the counselor, instructor, etc. that the deaf/hoh person will 
be meeting with.  If this is a field trip request, please provide all the details about
locations, times, etc.