HOME LANGUAGE SURVEY

Date   __________   

School  _____________________________   

Grade  _______

Student’s Name 

___________________________________________________

(First)                            (MI)                            (Last)

Parent or Guardian’s Name 

__________________________________________

(First)                 (MI)                      (Last)

Address 

_________________________________________________________

(Street)                             (City)                  (State)            (Zip)

Phone Number

 ____________________________________________________

(Home)                                                (Work)

1. Is there any language other than English spoken in the home? ___Y ___N

2. If yes, what languages are spoken in the home? ____________________

3. In what country was your child born? _____________________________

______________________________           

(Parent or Guardian’s Signature)

________________________________

(Date)