Interviewer:

Intake date:

2100 Blvd. des Laurentides, Vimont, Laval, Quebec. H7M 2R5 tle_literacy@yahoo.ca
Tel: (450) 688-2933 ext. 3126 Fax: (450) 663-1290

Stud ent’s Intake In terview

Date:

Name:

Address:

Postal code

*Birth date: / / 19
* optional Month Day Year

Mother Tongue:
Home tel. Work tel.
Other: Fax:
E-mail:
How did you hear about The Learning Exchange?
 SWL flyer  TLE ad/promo/PSA  Friend/family  SWL office/personnel
 Literacy council:  Referral agency:
 Other:

Background:

Last grade completed at school:

Where?
What are your expectations/goals:
Long-term goals:

Special skills/Interests:

  
  

Forms completed:

 Membership card issued  Student’s availability  Everyday Situations  Placement

Notes/comments:

D. Brown/ 2009