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Activity Provider Request
*
indicates a required field
Activity Provider Request
First Name
Required
*
Last Name
Required
*
Email
Required
*
I am:
Required
*
UC Student
UC Faculty/Staff
Visitor
Student ID (if applicable)
College/Organization/Unit To Be Billed For Services (If applicable):
Phone
(###) ###-####
Please indicate Phone Type
Required
*
Phone Number
Text Only
Video Phone
Name of individuals using Services:
Required
*
Name Of Additional Individual(s) Using Services (If Any):
Request Point of Contact
Required
*
Yourself
Other
Point of Contact Email
Type of Service
Required
*
Select Interpreter for ASL/English interpretation
Select Transcriber for CART/Realtime Captioning
For Notetaker see
Accessible Technology
For Video Captions see
Accessible Technology
Note Taker
Interpreter
Transcriber
Video Caption
Specific Communication Access Services
[select]
ASL Interpreting of Pre-recorded Media
ASL/English Interpreter (In Person)
ASL/English Interpreter (Virtual)
ASL/English Interpreter (In Person) & Realtime Captioning
ASL/English Interpreter (Virtual) & Realtime Captioning
Captions of Pre-recorded Media
Live Realtime Captioning (CART)
Transcript Only (Meaning-for-Meaning)
clear
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Activity Type
Required
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Advising Appointment
Campus Event
Conference
Presentation
Activity Name
Required
*
Activity Description
Required
*
Information about this event or request
Activity Date
Required
*
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February
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Activity Start Time
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Activity End Time
Required
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Activity Location
Required
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Building name
Address
Link for online services
Video Title
Required
*
File Type
Required
*
File Type
URL
File Type
Other
URL
Required
*
Other
Required
*
UC Staff Section
For Staff Use Only, Please Disregard
UC Staff Fields
UC Staff Fields
Yes
UC Staff Fields
No