If you would like to request a presenter from the A.R.M.E.D. program, print this page,
complete the form and fax or mail it to June Prusak.    Click here for contact information.

A.R.M.E.D. Request Form
(Adult Role Models in Education Deaf)
School Year: 2008- 2009

(please print & fax at  773- 248-9176 or mail at CHS Youth Program; 2001 N. Clybourn Ave, Chicago, IL 60614)

Name of School:                                                                        Name of Teacher:                                                    

Address:                                                                          City                                                          Zip                         

Phone #:                                             TTY/ V/VP    Fax #                                    Email:                                              

# of Students:                                      Grade Level:                                    Room Number:                                      

When do you want the deaf/hard of hearing presenter to come in?  What time?

What topic/area/occupation would you like the presenter to talk about? 

Do you have a specific deaf or hard of hearing presenter in mind? If so, who?

General Comments:                                                                                                                                                     

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