D.E.A.F. Inc. - Request to be Mentored or Tutored Form

	I would like to be Tutored or Mentored

	Please complete all of the blanks below. We will get back to you as soon as we can.

	Name

	Student/QA/Certification
	If student, where?
	Address
	City
	State
	Zip Code

	Home Phone
	Cell Phone
	Email Address
	Best time to contact you ?

	Describe what skills you would like help with
	What can you afford to pay for services?	Nothing up to $50.00 $51-$100.00 Over $100.00
	Are you willing to make a donation?	Yes No
	Are you willing to give back by providing pro bono interpreting for D.E.A.F. Inc.?	Yes No