2. To request a sign language interpreter or related service for persons who are Deaf, Hard of Hearing (HOH), Deaf/Blind, non-verbal users, etc. Please complete and submit your request at least 2 weeks prior to the start of the M-NCPPC sponsored program, activity or event. Authorized personnel with Disability Services will work to review and fulfill your request.

4. Date of Request*
   Date of Request
6. Patron Information

   This information refers to the individual who will be using the interpreter services. It allows Disability Services Staff to follow up with you as needed.

8. Patron Name*
10. Phone Number*
12. E-mail Address*
14. Best Method of Contact*

    1. Call
    2. Text
    3. E-mail
18. Program/Activity/Event Information
20. Program/Activity/Event Name*
22. Type of Program/Activity/Event*

    (I.e. class/program/event, theatrical performance, public forum, festival, drive-thru, etc.)

24. Program/Activity/Event Location
26. Facility/Park*
27. Address
29. This event is...*

    1. Indoors
    2. Outdoors
    3. Virtual
31. Type of Services requested:*
    -- Select One --ASLTactile/Close VisionCARTTrilingualVRICued SpeechOral
33. Other:

    If the service you're requesting is not listed.

35. Program/Activity/Event Date*
    Program/Activity/Event Date
36. Program/Activity/Event Time*
    Program/Activity/Event Time Start Time

    —

    Program/Activity/Event Time End Time

    Start and End time of the event

38. 
    

    Thank you for completing your online request. A representative with the M-NCPPC, Disability Services team will be in touch with you within five (5) business days.

    
    

    Northern Area Region
    Phone: 301-408-4350; E-Mail: Northern.Inclusion@pgparks.com

    Central Area Region
    Phone: 301-249-7200; E-Mail: Central.Inclusion@pgparks.com

    Southern Area Region
    Phone: 301-203-6000; E-Mail: Southern.Inclusion@pgparks.com

    Special Programs Division Office
    Phone: 301-446-3400; E-Mail: Program.Access@pgparks.com

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field