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ICSDeaf - VIP Registration

Registration for Deaf, Hard of Hearing and Hearing VIP members for ICSDeaf.
This membership includes:
• Special Raffles/Give-Aways
• Newsletter
• Interpreter Request Assistance
• Interpreter Confirmation (via-Email)
• List of Accessible Arts/Events

(This information will not be shared and it is kept CONFIDENTIAL)

Name * First Last
Gender
Date of Birth / MM / DD YYYY
Optional
Email *

Best e-mail to contact you.
Text Messaging Number - (###) - ### ####
Video Phone - (###) - ### ####
Instant Messenger/Social Networks

If you use: Text Message you can contact ICSDeaf at (305)761.4569
If you use: AIM/Yahoo!/MSN please send IM to our user name: ICSDeaf
If you have: MySpace/FaceBook or any other social network, us too: ICSDeaf
Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

This information is to help us determine which state and local news you would like to know about.
Language Preference/Fluency (Check all that apply): American Sign Language Signed-English English Spanish/Español Tactile/SSP (Deaf-Blind)
Indicate your Language(s) of preference.
Highest Education Completed Special Diploma High School Technical Training Associate's Degree Bachelor's Degree Graduate/Master's Degree Post Graduate
Household Income:
How often use/need Sign Language Interpreter?
Areas where use/need Interpreter: (Check all that apply) Special Diploma Education/Training Medical Legal/Correctional Performing Arts Social Services
Indicate where you need or use Sign Language Interpreters now.
More about YOU/Interests: Employed Un-employed (Help me find job) School Parents of Deaf/HoH Child[ren] Married to Deaf/HoH Married to Hearing Gay/Lesbian/Bi-sexual/Transgender Employer Sign Language for Babies Sign Language Storytelling Learning ASL
Check all that apply.
Please write details on the box provided next (below).
Details:

More about YOU/Interests:
• Where do you work?
• Where would you like to work?
• Where do you go to school?
• Deaf Child[ren]'s name.
• Deaf Spouse name.
• Where do you need interpreters?
How did you find us?
Do Not Fill This Out

Wufoo

ICSDeaf - VIP Registration

Instant Messenger/Social Networks