Literacy Volunteers of Rockland County
220 N. Main Street, New City, NY 10956
(845) 708-9072 Fax (845) 7-8-9072
STUDENT INITIAL CONTACT SHEET
Date ___________Have you applied to our program before today?__________
Family Name ____________________ Given Name _____________________
Date of Birth_________ Sex____ M_______ F_________
Address_______________________________________ Apt. ____________
City_______________________ State____________ Zip________________
Home Phone___________ Work / Cell ________________
How can we help you? (Check A or B)
A) I want to learn how to speak English _____Language spoken_____________
Name? Phone of friend who speaks English whom we can contact
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B) I already speak English and want to learn to read ____________
Best time of day for lessons _____ morning _____afternoon _____ evenings
In which libraries can you meet your teacher?
1) ____________________ 2) ____________________ 3) _________________
Do Not Write Below This Line
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WTBT _______ Sent to _________on _____________ to be tested
Was tested on __________________ by ______________ Sent to be matched_____________
Was matched with _______________________ on __________________________________
Status ______________________________________________________________________
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Date/Time ________________________Tester/Caller ______________ Comments__________
_____________________________________________________________________________
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