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 E-mail 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.

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