Experience Registration

	ARIZONA TOTAL IMMERSION Sign Language Program
	Experience Registration

Use this form to fill in your registration information. In order to complete your registration you must print the results (click the submit button) of this form and mail a check to PO Box 6446, Peoria, AZ 85385. The total cost is $595.00. The remaining $495.00 (after $100.00 deposit) is due no later than June 1, 2010.

* Required Fields

Registration - AZTI Experience, July 10 to July 14, 2010

Contact Information:

* Name

Male Female

Age

* Address

* City

* State

* Zip/Postal Code

Home Phone

Cell Phone

Work Phone

* E-mail

Emergency Contact:

* Name

* Phone

Alternate Phone

Please answer the following questions:

Are you:

Deaf? HH? Hearing?

Have you ever participated in a Total Immersion Program?

Yes No

If yes, where and when?

Level of Sign Language expertise:
(1 = beginner, 5 = advanced)

1	2	3	4	5

What is your Sign Language background and years of experience?

How did you hear about AZTI?

T-Shirts

Cost for each S, M, L, or XL is $10.00
Cost for each XXL, or XXXL is $12.00

Small

Medium

Large

X Large

XX Large

XXX Large

Yippie, I am an AZTI Vet I want my free T-shirt.

I have read the FAQ page of this website and understand I will not receive anything in the mail. I do understand that I will only receive an e-mail confirming my registration from the registrar.

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