Home Language Survey - PLEASE SUBMIT ONLINE

Student Name:*

Student Birth Date:*

Sex:*

Parent/Guardian Name:

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

Phone Number (cell) #1:*

Phone Number (work) #2:

Select School*

Grade*

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

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

What is the language that the student first acquired (spoke)?*

Was your child born in the United States?*

if YES, which state?

If NO, in what other Country? Please Describe

Has your child attended any other school(s) United States?*

If YES, Please List Name of School, State school is in and Dates the child attended.

Home Language Survey – PLEASE SUBMIT ONLINE