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
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DEAF, Inc. only:
Tuition Due _____________________
Payment Date____________________ Payment Cleared_________________
Payment Amount_________________ Receipt Sent_____________________
Payment Type___________________ Comments_______________________