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Home Language Questionnaire 2021-2022
The
purpose
of this survey is to ensure that your child receives the highest quality education and services to
which he or she is entitled. The information you
provide will be used only to assist the school in
making program decisions. You will complete this form only once in your child’s educational career.
PLEASE NOTE: SUBMIT EACH CHILD ON SEPERATE FORMS, THANK YOU. (If you have filled this form out for your child in previous years, you DO NOT NEED TO FILL THIS FORM OUT AGAIN!)
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* Indicates required question
Name of Child
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Does the student use a language(s) other than English with his/her family and friends?
*
Yes
No
Do you use a language(s) other than English with the student?
*
Yes
No
Does the student understand when someone communicates with him/her in a language other than English?
*
Yes
No
Does the student read in language(s) other than English?
*
Yes
No
Does the student write in a language(s) other than English?
*
Yes
No
Does the student interpret for you or anyone else in language(s) other than English?
*
Yes
No
What language(s) does the student use most frequently at home? Choose up to three
*
American Sign Language (ASL)
Arabic
Cantonese
Diné
English
French
Greek
Hmong
Jicarilla Apache
Italian
Keres
Khmer
Korean
Mescalero Apache
Mandarin
Portuguese
Russian
Somali
Spanish
Tiwa
Tewa
Towa
Vietanamese
Zuni
Other:
Required
Is the student transferring from another state, district, or school?
*
If yes, Please provide location and name of school in the "other" box.
Yes
No
Other:
Required
Has the student received schooling/education in a language(s) other than English?
*
If yes, please specify which language(s) in the "other" box.
Yes
No
In what language do you prefer to receive communication from the school?
*
Your answer
In what language would you prefer to communicate with school staff?
*
Your answer
Is there anything else we should know about how to best serve you child?
*
Your answer
Signature of Parent/Guardian: Date:
*
Parents/Guardians, please type your name here and type today's date.
Your answer
Translator, Language, Date
If a translator was needed to fill out this form, please put their name, the language they speak, and the date here.
Your answer
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