Local HLA of DC Application

Name ___________________________________	Date _____________________
Address_________________________________	City _____________________
State ___ Zip __________	Home Phone ________________
Work Phone ________________	Fax Number _____________
Primary Email___________________________________	Secondary mail_________________________

 

How did you find out about the HLA of DC Chapter? ___________________________

_____________________________________________________________________

Please give a reason for joining the HLA of DC Chapter:__________________________

_______________________________________________________________________

 

Are you a HLA National member?  (please circle) Y/N

Are you  (please check all that apply)

___ hard of hearing                 ___ deaf

___ parent of hoh/deaf children (please give the number of kids w/hearing loss____)

___ student (please give school/college)_______________________________

___ hearing healthcare provider     ___ Other

 

ASSISTIVE COMMUNICATION

Do you use  (please check all that apply)

__ ASL __ PSE __ Cued Speech __ Other (please describe)

 

ASSISTIVE TECHNOLOGY

Do you use (please check all that apply)

 

__ CART	__ C-Print	__ Inductive loop	__ Personal ALD
__ FM	__ Infra-red	__ Other (please describe)

 

Disclaimer:  The preferences you declare may be used for program planning consideration only. HLA of DC does not have the resources to pay for these services. If services were provided pro-bona then the HLA of DC board may consider integrating them into a given program.

 

Are you interested in (please check all that apply)

__ Publicity                  __ Officers

__ Newsletter                 __ Other  (please describe) ___

__ TV Production              _______________________________

 

Newsletter:

Do you want to receive an electronic version of the newsletter?  ___ yes  ____ no

 

Annual Contributions

Date you wish to join HLA of DC ________________________

$ 10.00 HLA of DC Chapter Fees/Newsletter

$______ Newsletter Ad 50 dollars per issue

$______ Donation              $______ Total Amount Enclosed

 

Please make checks payable to HLA of DC and mail to: Paula Preston 613 Quincy St NW Washington DC 20011

If you have any questions related to chapter fees or other financial matters, please send email to HLA_of_DC@yahoo.com.  Thanks for your support!