Indigenous Membership Form

alberta cultural society of the deaf Membership Application

FREE
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
YesNo
YesNo
I give permission for ACSD to take and use my photos/videos for promotional purposes (website, social media, etc.)I do not give permission.
I confirm that I am 18 years of age or older.I am Deaf, Deaf-Blind, or Hard of HearingI can communicate fluently in ASL or LSQ and/or ISLI read and acknowledge my benefits as an indigenous member.My ACSD membership is free for life. If I ever want to cancel, I will contact ACSD directly.I have a proof of status card to be shown or discussed with Indigenous Director, and I will send it to infoacsdoffice@gmail.com
Date of Signature*

MonthDayYear
Date
Signature*
Should be Empty:

alberta cultural society of the deaf Membership Application