PW-MSHS Schools - New Student Only - Home Language Survey

Pewamo-Westphalia Community Schools

5101 Clintonia Rd. Westphalia, MI 48894 * 989.587.5100
State Board of Education Approved Home Language Survey

(Translation of this survey form in Spanish, Arabic, French, Italian, and Ojibwa is available at the Office of Field Service.)
The Pewamo-Westphalia School District is collecting information regarding the language background of each of its students. This information will be used by the district to determine the number of children who should be provided bilingual instruction according to Sections 380.1151-380.1158 of the School Code of 1976, Michigan's Bilingual Education Law. Thank you very much for your cooperation.
Student name: *

First Name Last Name
Student grade: *
Student age: *
School building: *
In the following questions, the term, "Primary language" is used to mean "dominant language" used by the person for communication.
Is your child's native tongue a language other than English? *

Yes No
If yes, what is that language?
Is the primary language used in your child's home or environment a language other than English? *

Yes No
If yes, what is that language?
Parent/guardian signature: *

Clear
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date *

Month Day Year
Date
Should be Empty:

Pewamo-Westphalia Community Schools