Home Language Survey Form

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SCITUATE PUBLIC SCHOOLS
Home Language Survey
Name of Student: _______________________________________ Age: _______________
Parent/Guardian Name(s): ______________________________________________________
School: ____________________________________________ Grade: ________________
Dear Parent(s)/Guardian(s):
In order to help your child succeed in school, we ask that you please answer the following questions for
each child in your family. Your answers will help us in creating the best possible educational program for
your child.
1.
What language did your child first understand or speak?
2.
What language do you use most often when speaking to your child at home?
3.
What language does your child use most often when speaking to you at home?
4.
What language does your child use most often when speaking with other
family members?
5.
What language does your child use most often when speaking with friends?
6.
What language(s) does your child read?
7.
What language(s) does your child write?
8.
At what age did your child start attending school?
9.
Has your child attended school every year since that age?
Yes _________
No ___________
If no, please explain:
10.
Do you require communication from school in a language other than English?
Yes _________
No ___________
If Yes, please indicate the required language: ________________________
_________________________________________________
___________________
Signature of Parent/Guardian
Date
To be completed by ELL Program Staff Before Placement:
Date/School
Student First Name
Student Family Name
Date of Birth
Enrollment:
___/_____/______
Relationship of Person Completing Survey:
 Mother
 Father
 Guardian
 Other Specify: _________________________________
Recommendation:  Proficiency Testing/Records Review
 No ELL Services
Signature of ELL Staff: _____________________________________________ Date: _____________
cc: School Principal, ELL Services Coordinator, Guidance Counselor, Student Cum. File

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