GISN - Onsite Request Form

GISN - Request for Onsite Sign Language Interpreting Services

Note: if your event takes place in less than 48 hours or if you have not received that your request was processed within two business days, please call us for immediate assistance at (800) 228-4992 or (404) 521-9100.
Do you have an existing GISN customer agreement signed?*

YesNo
If you answered no, you must contact request@gisn.info in order to complete the GISN Customer Agreement before requesting a service.
Your Agency Name*
Authorized Requester Full Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Phone
Please enter a valid phone number.
Billing Contact Full Name*
Billing Contact Phone*
Please enter a valid phone number.
Has your Billing Information Changed?*

YesNo
If yes, please list any changes
Event Details
Event Start Date *

MonthDayYear
Event End Date *

MonthDayYear
Start Time *

Hour Minutes

AM/PM Option
End Time*

Hour Minutes

AM/PM Option
If your event has different start and end times list them here.
Event Location - Include Business Name, Full Address, Building #, Room #, Class or Teacher Name, etc.*
Parking Instructions - What is expected (validated parking, on-site parking, free parking, paid parking (fee), parking lot name, etc.)*
Onsite Contact Person*
Phone Number*
Please enter a valid phone number.
Emergency Contact Person Name (for cancellations, etc.)*
Emergency Contact Phone Number*
Please enter a valid phone number.
Name of Deaf person(s)*
Nature of Appointment*
Medical record #
Case/Code #
A&I # (if applicable)

Please indicate the # of participants present at appointment/ conference/ training, etc.:*

	Deaf/Hard-of-Hearing	Hearing	Deaf/Blind
Adults
Minors (17 and under)

Sign Language Preference(s)*

American Sign LanguageContact SignEnglishTactileUnknown
Other disabilities
Additional Information
Specific Interpreter Requests - Preferred Interpreter Name(s), Attire, Gender, etc.
Additional Information - Please provide as much information here about what is to be interpreted, including names of other parties involved, presentation transcripts, procedures to be performed, file or case numbers, etc.)
Please Note: GISN would like to get your approval/declined should the interpreters continue past the requested time, at any time an approval is granted, interpreters will continue until the event is finished. The requested time will be adjusted. Please reply with your consent or decline for interpreters to continue.
Additional Email Address to be added to Confirmation Emails:
P.O. Box 2945, LaGrange, GA 30241

www.gisn.info
Should be Empty:

GISN - Request for Onsite Sign Language Interpreting Services

Event Details

P.O. Box 2945, LaGrange, GA 30241