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

SUMMER PROGRAM QUESTIONNAIRE

STUDENT’S NAME: ______________________________ DATE OF BIRTH: ____________ ADDRESS: ___________________________________________________________________ SCHOOL ATTENDING: _________________________________________________________ TELEPHONE #: ___________ FAX #: ___________ E.MAIL: _________________________ PARENT'S NAMES: ____________________________________________________________ The information requested below will enable the staff of Educational Futures to develop appropriate recommendations. Please provide complete information for this purpose. GENERAL OBJECTIVE(S): ______________________________________________________ ______________________________________________________________________________ DATES AVAILABLE: __________________________________________________________ PREFERED LOCATION: ________________________________________________________ 1. SUMMER SCHOOL: SECONDARY LEVEL _________           UNIVERSITY LEVEL _________ 2. SUMMER CAMP: RECREATIONAL _________                  EDUCATIONAL _________ 3. WILDERNESS: MOUNTAIN _________           LAKE/RIVER _________     OCEAN _________ 4. SPECIAL PROGRAMS: PERFORMING ARTS _________           SCIENCE/COMPUTER _________ RELIGIOUS _________                           REMEDIAL _________ ENVIRONMENT _________    LEADERSHIP _________    FITNESS _________ 5. SPORTS CAMPS: TENNIS _________                  GOLF _________                 WATER _________ OTHER ___________________________________ 6. LANGUAGE     PROGRAM: ENGLISH _________               OTHER(S) ________________ 7. SPECIFY: __________________________________________________________________ __________________________________________________________________ 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.