Home Language Survey
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
State / Country
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? ____/____/____
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:
Language(s) spoken:__________________________________ Telephone:___________________
THIS MUST BE COMPLETED BY SITE STAFF:
Coming from______________________ _____________________ or ________________________ or ___________________
Original – Student’s CUM folder
Revised March 2007