'Gaeltacht' Week 2004 - Registration Form

Name
Address
City State Zip

Phone:
[Day] [Night]
[Fax] E-Mail:

Age if under 14

Where do you attend classes?
With whom do you study?

Are you?

How long have you studied Irish?
No Previous Study Months Years

Ability:
On a scale of (low) 1 to 10 (high), how would you rate your level of Irish?

Please mark off all of the following that pertain to your Irish language skills.

Odd words and phrases Can understand a bit

Can speak a bit Can read & write a bit

Very simple conversation Can read & write better than converse

Some Fluency:

I can take passengers from:
I need a ride from:

Return this Form, with check payable to:

Ethel Brogan
56 Derick Drive
Fishkill, NY 12524-1002

If confirmation of your reservation is required, please enclose a stamped, self-addressed envelope.

REGISTRATION FORM