Arlene Long Memorial Fund Application

Applicant Contact Information

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Type of phone

Voice

Videophone

Other

Category of funding

Interpeter

Sign Language Teacher

Additional Training

Other

Total years of experience

Number of Years as an Interpreter/Sign Language Teacher

Please describe your goal and how this additional training will help you achieve it

If you receive this funding, how do you plan to give back to DHCC and the Deaf community?

Title

Cost

Location

Instructor

Dates of class/workshop

Flyer/details of class

I have read and understood the Terms and Conditions of the Arlene Long Memorial Fund/Scholarship.

If selected as the recipient, I will abide by these rules.

Signature