Interpreter Outreach Services Request Form

Tennessee Schools for the Deaf Logo

Interpreting Services for the Deaf and Hard of Hearing

Interpreter Outreach Services

2725 Island Home Blvd

Knoxville, TN 37920

Please submit request two weeks prior to expected date of visit.

Who is requesting the visit?*

Answer required for "Who is requesting the visit?"

School District*

Answer required for "School District"

School Assigned*

Answer required for "School Assigned"

Interpreter Supervisor Contact Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Email 1*

Answer required for "Email 1"

Mobile Phone*

Number Required

Work Phone

Number Required

Interpreter Contact Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Email 1*

Answer required for "Email 1"

Mobile Phone*

Number Required

Work Phone

Number Required

Requester's Contact Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Email 1*

Answer required for "Email 1"

Mobile Phone*

Number Required

Work Phone

Number Required

List any interpreter resources needed:

Answer required for "List any interpreter resources needed:"

Reason for visit being requested:*

Answer required for "Reason for visit being requested:"

Has the parent / guardian given permission to release or share information with TSD Interpreter Outreach Services?*

Answer required for "Has the parent / guardian given permission to release or share information with TSD Interpreter Outreach Services?"

Yes

* Authorization to release information (1 form per student) must be signed by the parent / guardian and recieved by the TSD Interpreter Outreach Services prior to scheduling the visit.

Please visit the TSD Interpreter Outreach for a fillable and printable Authorization to Release Information PDF.

Please scan and send via email to Danielle Petersen [email protected] using "Interpreter Outreach Authorization" in the subject line to the attention of TSD Interpreter Outreach Services.

Additional information related to the request:

Answer required for "Additional information related to the request:"

Please fix the highlighted areas below before submitting.

Interpreter Outreach Services Request Form