Disaster Response Interpreter Training Application

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-02036 (02/2017)

DISASTER RESPONSE INTERPRETER TRAINING APPLICATION Great Wolf Lodge, Wisconsin Dells Saturday, April 29, 2017 8:00 a.m. – 5:00 p.m. Sunday, April 30, 2017 8:00 a.m. – 12:00 p.m.

FAX or MAIL the application by March 27, 2017 to: Office for the Deaf and Hard of Hearing Attn: Carly Bieri 1 W. Wilson Street, P.O. Box 2659 Madison, WI 53701-2659 Fax: 608-264-9899 Your Full Name Phone Number

Mailing Address City State Zip Code WI Email Address

Freelance Are you currently employed through an Interpreter Agency Yes No Yes No If yes, please list name:

Applicant Experience and Information Interpreting Credentials RID Member Number

Wisconsin Sign Language Interpreter License Number Number of Years Interpreting #150 or #151 Types of Interpreting Educational Legal/Law Enforcement Disaster Medical Media Community/Social Services

Other, Please list: Other Relevant Experience/Training

RIDCMP 0.8 Professional Studies, Content Level: Some, offered through WisRID an RID CEUs approved RID CMP sponsor.

*Please attach your resume and a letter of interest.

I certify that the above is true and correct. SIGNATURE – Applicant Date Signed FAX OR MAIL NO LATER THAN FRIDAY, MARCH 27. 2017.