VASLTA Membership Form

Please print clearly.

Name    _______________________________________________________

Address _______________________________________________________

City    ______________________________ State ______ Zip Code  ______ 

Phone     (H)    (      ) ____________________   TTY   V
	
          (W)    ( 	) ____________________   TTY   V

          (Fax)	 (	) ____________________

Do you have a TTY answering machine?    Yes	No

Email____________________________________________________________

Please check if you are: (for directory purposes)

                ____ Sign Language Teacher

                ____ Deaf Culture Specialist

                ____ Interpreter or Interpreter Trainer

                ____ Educator of the Deaf

                ____ Other (please specify) __________________________________

                                            __________________________________

Are you certified by ASLTA? If so, what level?




What is the highest degree you have?




Specify level of class, if you teach ASL (currently or previously).




How many years of teaching ASL?




Are you currently teaching ASL? Where?




Do you want your name, address, and phone number printed in our directory?    Yes	No

Join VASLTA for $15     $ _________  [Effective September 01, 2003]

Donation to VASLTA      $ _________

             Total	$ _________

Please make the check payable to: VASLTA, and mail the check with this detached form to:

                        VASLTA
                        c/o Paula Debes
                        8544 Rothbury Drive
                        Bristow, VA 20136