Home Language Survey
Sign in to Google to save your progress. Learn more
In order to assist the School District of Rhinelander in communicating with our families, please answer the following questions about your family’s language.  The information on this form helps us identify students who may need help to develop the English language skills necessary for success in school.  Language testing may be necessary to determine if language supports are needed by your child.  Answers will not be used for determining legal status or for immigration purposes.  If your child is identified as eligible for English language services, you may decline some or all of the services offered to your child.  
Student Name *
Grade *
Date of Birth *
MM
/
DD
/
YYYY
Person Completing Survey *
Relationship of Person Completing Survey *
Preference for Oral Communication *
Preference for Written Communication *
Check the correct response for each of the following questions and indicate other languages if appropriate.
1.  Was the first language used by this student English? *
2.  When at home, does this student hear or use a language other than English more than half of the time? *
3.  When interacting with their parents or guardians, does this student hear or use a language other than English more than half of the time? *
4.  When interacting with caregivers, other than their parents or guardians, does this student hear or use a language other than English more than half of the time? *
5.  When interacting with their siblings or other children in their home, does this student hear or use a language other than English more than half of the time? *
6.  Is this student a Native American, Native Alaskan or Native Hawaiian? *
7.  Is this student's language influenced by a Tribal language through a parent, grandparent, relative, or guardian? *
8.  Has this student recently moved from another school district where they were identified as an English learner? *
Parent/Guardian #1 Electronic Signature *
Date completed *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of School District of Rhinelander. Report Abuse
Google Forms