DEAF, Inc. Adult Education Classes online Application Form- Print Version

Instructions: Type or print clearly in black or blue ink. Answer all questions. Mail to ASL Program, DEAF, Inc., 215 Brighton Avenue, Allston , MA 02134

American Sign Language Classes for All (Hearing, Deaf, Deaf Blind, Hard of Hearing)

Course: Circle One
ASL I / ASL II / ASL III / ASL IV / ASL V / Finger Spelling

Name (print): _______________________________________________________________________

Date of Birth: ____________________

Address: ___________________________________________________________________________

City/State/Zip Code: _________________________________________________________________

E-Mail: ____________________________________________________________________________

Phone Number: _____________________________________________ VP / TTY / Voice

How did you hear about our ASL classes? __________________________________________

Do you get emails, letters or flyers from DEAF Inc.? Yes / No

If no, do you want us to send you letters and flyers? Yes / No

What is your ethnicity: White / Black / Hispanic / Asian / Native American / Other________________

Circle One: Deaf / Deaf Blind / Hard of Hearing / Late-Deafened / Hearing

Do you get support from MRC? Yes / No

If yes, who is your Counselor? _________________________________________________________

To the best of my knowledge, the information I wrote on this form is true:

______________________________________________________________
Student Signature

______________________________________________________________
DEAF, Inc. Signature

_______________________________
Date

*******************************************************
DEAF, Inc. only:

Tuition Due _____________________
Payment Date____________________ Payment Cleared_________________
Payment Amount_________________ Receipt Sent_____________________
Payment Type___________________ Comments_______________________