ASL IMMERSION 2013 REGISTRATION FORM

(PLEASE PRINT CLEARLY)

NAME(S) 1. 2.

3. 4.

ADDRESS: POSTAL CODE:

PHONE: Home: ( ) Work: ( )

Fax: ( ) Email/Text:

PLEASE CHECK (b) YOUR LEVEL OF ASL EXPERIENCE JULY 8 – 12th, 2013

BEGINNERS 1 (KNOW ZERO OR NOT YET TAKEN FULL ASL COURSE)

BEGINNERS 2 (TAKEN B1 OR NOT CONFIDENT IN Beginners 1 or 101)

INTERMEDIATE 1 (40 TO 80 HRS OF ASL; 101 AND / OR 102)

INTERMEDIATE 2 (120 TO 160 HRS OF ASL; 103 AND / OR 201)

INTERMEDIATE 3 (200 TO 240 HRS OF ASL; 202 AND / OR 203)

ADVANCED 1 (IF NOT SURE, ASK SANDY / RITA)

ADVANCED 2 (IF NOT SURE, ASK SANDY / RITA)

HAVE YOU TAKEN THE ASL IMMERSION BEFORE? NO ___ YES , IF YES, WHAT YEAR & LEVEL?

Do you feel confident and ready for a higher level? YES ___ NO___ Or would you prefer to

repeat the same level? Please comment: ______

If Youth – do you have a one-to-one worker in your school/ day program? Yes ____ No____

PAYMENT: CASH CHEQUE TYPE OF CREDIT CARD:

NAME ON CREDIT CARD:

CREDIT CARD NUMBER: EXPIRY DATE:

SIGNATURE OF NAME ON CREDIT CARD

Cheques: Make payable to SMD SERVICES. On bottom of cheque please write “ASL Immersion 2013”

Complete and return to / or request information regarding registration from:

Sarita Blake Phone: 204 975 3107 VOICE

SMD Deaf and Hard of Hearing Services 204 975 3083 TTY

825 Sherbrook Street Email:

Winnipeg, MB R3A 1M5

1 866 282 8041 EXT 3107 Voice / Toll Free MB 1 800 225 9108 TTY/Toll Free MB

For information regarding curriculum, signing levels, etc. please contact:

Sandy Lysachok Phone: 204 975 3080 VOICE EMAIL:

Rita Bomak Phone: 204 975 3077 TTY EMAIL:

1 866 282 8041 EXT 3080 Voice Toll Free or 1 800 225 9108 TTY Toll Free

The Fun & Sign is a recreation program for children age 5 – 12, whose parents/family is attending the ASL Immersion. We will send you an in-depth registration form. Please note this is NOT a school program for Deaf children. If you would like to register your children – please fill out below:

Child(ren)’s name(s): Male/ Age Allergies Deaf/ HH Female

SMD SERVICES CONSENT FOR SHARING NAME(S) – MUST FILL OUT

The ASL Immersion is provided by SMD Services. The program is held at the Manitoba School for the Deaf, which is under the Provincial Government. Please sign below so that your name can be: 1. Printed in the ASL Immersion program book; 2. Given to both the Manitoba School for the Deaf and the Provincial Government, so that they are informed as to who is in their building.

I, (PLEASE PRINT) give my permission to SMD Services to share the names of myself and my immediate family with the Manitoba School for the Deaf, the Province of Manitoba, and Government Services.

SIGNATURE: DATE:

STUDENTS WISHING TO STAY IN MSD’S RESIDENCE: Must be 18 years of age or older, or be with a parent /guardian. Some of the dorm rooms sleep 2 people and some sleep quite a few. Please write the name(s) of the people with whom you would like to share a room, and indicate male, female or if you are a family and the number of people. If there are many requests for residence we cannot provide single rooms.

NAME(S): PLEASE PRINT CLEARLY MALE / FEMALE DEAF / HH

ALLERGIES

NAME OF INDIVIDUAL TYPE OF ALLERGY AND DO YOU CARRY AN EPI-PEN?

OFFICE USE ONLY

CONFIRMATION
LETTER
/ LUNCH
/ MSD MAP
SENT
YES NO / MSD RESIDENCE
LETTER SENT
YES NO / B1 -A, B, C
SENT
YES NO / FUN & SIGN PROG
APP COMPLETED
YES NO

February 2013