HOME LANGUAGE QUESTIONNAIRE (NS)(5)

HOME LANGUAGE QUESTIONNAIRE (NS)(5)
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Today's Date

MonthDayYear
Date
Student*

First NameMiddle NameLast Name
Students Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*

K123456789101112
Has your child attended school in another country?*

YesNo
If yes, how many years?
If yes, what country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Language used for instruction *
All students enrolled in our school district need to have their parent(s) or guardian(s) complete and sign this form. We value a student's ability to speak a language other than English and we encourage the student to maintain those language skills. However, if a student is having difficulty speaking, reading or writing the English language, we want to help him/her improve English language skills.
Is any language other than English spoken in your home?*

YesNo
If yes, what is the other language?
Did you child learn to speak a language other than English before learning English?*

YesNo
Please describe the language spoken by your child by checking one response below.*

Speaks no English, only the other languageSpeaks some English, mostly the other languageSpeaks English and the other languageSpeaks mostly English and some of the other languageSpeaks only English
Please describe the language understood by your child by checking one response below.*

Understands no English, only the other languageUnderstands some English, mostly the other languageUnderstands English and the other languageUnderstands mostly English and some of the other languageUnderstands only English
Which of the following best describes the language spoken in the home by parents and other family members?*

Only the other language and not English is spokenMostly the other language and some English is spokenThe other language and some English is spokenMostly English and some of the other language is spokenOnly English is spoken in the home
Parent Legal Guardian*

First NameLast Name
Signature*
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