EDUCATIONAL FUTURES 191 Main Street New Canaan, CT 06840 Tel:  (203) 966-6993 Fax:  (203) 966-3832 E-mail: EduFutures@aol.com

ENGLISH LANGUAGE PROGRAM REQUIREMENTS

STUDENT'S NAME: ____________________________________  DATE OF BIRTH: _________________ ADDRESS: ____________________________________________________________________________ TELEPHONE: ________________________   FAX: _______________________ E.MAIL ADDRESS: _________________________________________________ SCHOOL ATTENDING/ED: _______________________________________________________________ DIPLOMA RECEIVED: _____________________________________________   YEAR: _______________ LANGUAGE OF INSTRUCTION: ___________________________________________________________ FIRST LANGUAGE: ___________________________________ YEARS OF ENGLISH STUDY: _________ DATES AVAILABLE: ______________________________________ LOCATION PREFERRED: __________________________________ PREFERRED LIVING:     COLLEGE/UNIVERSITY CAMPUS: _______________                                   APARTMENT: ______________   FAMILY:______________ OTHER REQUIREMENTS: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please fax this completed form to 203-966-3832. Upon receipt of the questionnaire and the Contract for Services, we will recommend programs for your consideration.