Student Home Language Survey

Student Name

First Middle Last

Parent/Adult Supporter Name

First Middle Last

Country of Birth

Date of Birth

Grade/Date first enrolled in a U.S. school

Name of Former School and Location

Last or Current Grade

What language did you/your child first understand and speak?

What is the primary language used in the home?

Which languages do you/your child use? Click the + to add additional languages.

Language

Would you prefer to receive written information from school in a language other than English?

Yes

What language?

Would you prefer for the school to arrange for an interpreter to be available to you free of charge during meetings and phone calls?

Yes

What language?

Is there anything else you think is important for the school to know?