Home Language Survey - PLEASE SUBMIT ONLINE

Student Name:*

Student Birth Date:*

Sex:*

Female
Male

Parent/Guardian Name:

Address: (street, city, state, zip)*

Phone Number (cell) #1:*

Phone Number (work) #2:

Select School*

Grade*

Was your child born in the United States?*

If yes, which state? (type NA if doesn't apply)*

If not, in what other country? (type NA if doesn't apply)*

Has your child attendend any other school United States for any three years during their lifetime?*

If yes, please provide school name(s), state(s) and dates attended:*

Name of School, State, Dates

In which language do you prefer to receive written information from school?

In which language do you prefer to receive spoken information from school?

What is the primary language used in the home, regardless of the language spoken by the student?*

What is the language most often spoken by the student?*

What is the language that the student first acquired?*

Parent/Guardian Signature: By typing your name in the box below, you agree that the information provided is accurate and this serves as a signature on your behalf:

Signature

Today's Date

Date of Signature

Home Language Survey – PLEASE SUBMIT ONLINE

Home Language Survey Registration 25-26