2011 Summer Catalog - Gallaudet University

Section I: Program Information (Please indicate which program you are interested in attending):
REGISTER NOW! ● Enrollment Limited ● Deadline May 27,2011
Knowledge for College: July 10 - July 23 $1650 Life After High School: July 16 - July 23 $1250
Immerse into ASL: July 10 - July 23 $1650 The Play's the Thing: July 10 - July 23
Section II: Personal Information
Adult t-shirt size: Small Medium Large X-large
If T-shirt size is not indicated, a medium shirt will be ordered for your child.
Name: ________________________________________________________________________________
Address: ______________________________________________________________________________
City/State Zip: __________________________________________________________________________
Phone/Day: (__ __ __) ___ ___ ___- ___ ___ ___ ___ Phone/Evening: (__ __ __) ___ ___ ___- ___ ___ ___ ___
Voice TTY VP Voice TTY VP
Email Address: _________________________________________________________
Sex: Male Female Hearing Status: Deaf Hard of Hearing Hearing Other_______________________
Ethnicity:
Are you Hispanic or Latino? Yes No
American Indian/Native Alaskan
Asian American
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Citizenship:
Grade in Fall:______ Birthdate: __ __/__ __/__ __ __ __
MM/ DD/ YYYY
School Name:__________________________________________________________________________
My school is:
Residential School for the Deaf (residential students or day students) Resource Room
Day School for the Deaf (day students only) Self-contained class (deaf students only)
Public School with interpreting services Other_______________________
Public School without interpreting services
Section III: Emergency Contact Information
Emergency # 1
Name: _______________________Relationship:____________
Phone/Day: (__ __ __) ___ ___ ___- ___ ___ ___ ___
Voice TTY VP Cell
Gallaudet University
Phone/Evening: (__ __ __) ___ ___ ___- ___ ___ ___ ___
Voice TTY VP Cell
Pager/Email: ____________________________________
Youth Programs 2011
USA/Native
Permanent Resident
Temporary Resident
Other___________________
Communication Used:
ASL
Signed English
Cued Speech
Oral
Other______________________
Special Accommodations:______________________________________
Emergency # 2
Name: _______________________Relationship:____________
Phone/Day: (__ __ __) ___ ___ ___- ___ ___ ___ ___
Voice TTY VP Cell
Phone/Evening: (__ __ __) ___ ___ ___- ___ ___ ___ ___
Voice TTY VP Cell
Pager/Email: ____________________________________
Gallaudet University • Summer Programs • 800 Florida Avenue, NE; HMB 141 S; Washington, DC 20002 • Tel: 202/448-7272 (tty/v) • Fax: 202/651-5987
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