2018 - 2019 Home Language Survey/Race/Ethnicity Form
What is your name? *
Your answer
Student's Last Name *
Your answer
Student's First Name *
Your answer
Birth Date *
Your answer
Sex *
Required
Parent/Guardian Name *
Your answer
Address *
Your answer
Home Phone Number *
Your answer
Work Phone Number *
Your answer
School: *
Grade *
Was your child born in the United States? *
If yes, in which state?
Your answer
If no, in what other country?
Your answer
Has your child attended any school in the United States for any three years during their lifetime? *
If yes, please provide school name(s), state, and dates attended:
Your answer
What language is spoken by you and your family most of the time at home? *
Your answer
If available, in what language would you prefer to receive Communication from the school? *
Your answer
Is your child’s first-learned or home language anything other than English? *
What language did your child learn when he/she first began to talk? *
Your answer
What language does your child most frequently speak at home? *
Your answer
What language do you most frequently speak to your child? *
Your answer
Please describe the language understood by your child (Check only one) *
Required
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Parent or Guardian’s Signature *
Your answer
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