Road to Deaf Interpreting

Subtitle

All information is kept confidential. Please print and send by June 30th, 2017 for New England residents and by July 29th for non-New England residents to: Jim Lipsky c/o Road to Deaf Interpreting, 95 Prince Street, Jamaica Plain, MA 02130 with $10.00 application fee payable to "Road to Deaf Interpreting".  A $20.00 fee will be assessed for any bounced checks.  All payments are non-refundable.   
Name 
 
Mailing Address 
 
Permanent Address 
 
Email Address 
Phone ? HomeVoice_____ VP _____
Phone ? WorkVoice_____ VP _____
Birthdate 
 
Interpreting Certification (if any)  
 

 

Educational History 

 School City, State Degree Dates of attendance 

1. 

2.  

3.  

 
Work History
      Employer  City, State Job Title Dates of employment  

1. 

2.  

3.  

Memberships in organizations or Clubs 
 
 
What is your primary language? 
 
 
How did you learn ASL (that is, through deaf family members, residential school, in college)?   
 
 
 
Have you taken informal classes or workshops with focus on ASL generally? (e.g. linguistics, literature, grammar and usage, culture, deaf history)?  Please list dates and titles of courses taken.      Attendance Dates Course title  

1.

 

2.

 

3.

Have you taken informal courses or workshop which focus on English generally? (e.g. linguistics, literature, grammar and usage, culture, deaf history)?  Please list dates and titles of courses taken.      Attendance Dates Course title  

1.

 

2.

 

3.

 
 
 

Specifically, have you ever participated in a previous interpreter training program? (e.g. Interpreter workshops, college courses weekend intensives)?  Please list dates and titles of courses taken.      Attendance Dates Course title  

1.

 

2.

 

3.

Do you currently work as a Deaf interpreter?   
Yes _____ NO ____  

If so, how often to you interpret?

Do you currently work as a Deafblind interpreter?  
Yes _____ NO ____  

If so, how often to you interpret?

Describe generally, the setting or situations in which you have been interpreting

(e.g., court, medical, group home, counseling)

Also describe the language(s) used by the consumers in those settings.

 
What do you hope to learn from this workshop series? 
 
 
 
 
 

 References

 Please list names and relationships (Two are required). Those people must be professional relationships in  interpreting, ASL, or other related field.  At least one reference must come from a Deaf person. 

 1.  _____________________________________________________________________

 2.  _____________________________________________________________________ 

 

 Office only:       Date of Received:  ___________________  Completed Application form  ___ Check/money order  of $10___  One required videoclip   ___  Two letters of recommendation

 

 

 

 

 

 revised 6/1/17

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