New Student Enrollment Student Information Sheet (Page 3 of 4) in pdf

Bremen Public Schools

512 W. Grant St.

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Bremen, IN 46506

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574-546-3929

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574-546-6303 (fax)

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Home Language Survey (HLS)

The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and

charter schools to determine the language(s) spoken in each student’s home in order to identify their specific

language needs. This is information essential in order for schools to provide meaningful instruction for all

students as outline Plyler v. Doe, 457 U.S. 202 (1982).

The purpose of this survey is to determine the primary or home language of the student. The HLS must be given

to all students enrolled in the school district/charter school. The HLS is administered on time, upon initial

enrollment, and remains in the student’s cumulative file.

Please note that the answers to the survey below are student-specific. If a language other than English is

recorded for ANY of the survey questions below, the LAS Links placement test will be administered to

determine whether or not the student will qualify for additional English language development support.

Please answer the following questions regarding the language spoken by the student:

Student’s Name: _____________________________________________ Date of Birth: ___________________

Grade: _____________ School Year: _____________

1. What is the native language of the student? ________________________________________________

2. What language(s) is spoken most often by the student? _______________________________________

3. What language(s) is spoken by the student at home? _________________________________________

________________________________________________________________________________________

By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a

language other than English has been identified, your student will be tested to determine if they qualify for English language

development services, to help them become fluent in English. If entered into the English language development program, your

student will be entitled to services as an English learner and will be tested to determine their English language proficiency.

PARENTS ONLY: Do you prefer to receive information in ___ English or ___ Spanish? (Please mark only one)

Migrant Program: Within the last 3 years, has your child(ren) moved from one school district to another with a

parent, relative or guardian so that person could look for seasonal or temporary work in agriculture?

(Plant or

harvest vegetables or fruits, detassel corn, tobacco farm, poultry and/or egg farm, duck, turkey, chicken, pork or beef processing

plant, aquaculture/fish hatcheries, canning vegetables or fruits, sod farm, planting, pruning, or cutting trees, dairy farm, flora

culture/gladiola farm, green house or plant nursery)

___ Yes

___ No

If Yes, a work survey will be sent to you to complete.

New Student Enrollment Student Information Sheet Page 3