Home Language Survey Form - English printable pdf download

Home Language Survey

English

TO BE FILLED OUT BY PARENT OR GUARDIAN:

California Education Code 52164.1(a) states that “the primary language of new pupils shall be determined as they enroll in the school district”. This

requires schools to determine the language(s) spoken at home by each student. This information is essential in order for schools to provide meaningful

instruction for all students. Your cooperation in helping us meet this important requirement is requested. Please answer the following questions and have

your son/daughter return this form to his/her teacher. Thank you for your help.

Name of Student___________________________________________________

M / F

_____

______/_____

_____/_____/_____

Last

First

Middle

Grade

State / Country

Month /

Day /

Year

Place of Birth

Date of Birth

Which language did your son or daughter learn when he or she first began to talk?

______________________________________

Which language does your son or daughter most frequently use at home?

______________________________________

Which language do you use most frequently to speak to your son or daughter?

______________________________________

Name the language most often spoken by the adults at home:

______________________________________

When did your child first enter a school in the U.S.? ____/____/____

In California? ____/____/____

PARENT SIGNATURE

DATE

________________________________________________

_____________________________________

If you can speak a language other than English and are willing to help tutor or translate for students who do not speak English, please indicate below.

I would be willing to volunteer:

Yes

Language(s) spoken:__________________________________ Telephone:___________________

THIS MUST BE COMPLETED BY SITE STAFF:

Site:

Capistrano

Empire

Hughes

Sipherd

Stroud

Glick

Teel