Birmingham City Schools

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HOME LANGUAGE SURVEY

Student Name: *

Birth Date: *

Sex *

Address *

Home Telephone *

Work Telephone *

School *

Grade *

Option 1

Today's Date *

Was your child born in the United States? *

Yes

If yes, which state? *

Has your child attended any school in the United States for any three years during their lifetime? *

Yes

If yes, please provide school name(s), state, and dates attended: *

What language is spoken by you and your family most of the time at home? *

If available, in what language would you prefer to receive communication from the school? *

Please check if your child is: *

Native American Indian

Alaska Native

Native Pacific Islander

Native U.S. Virgin Islander

Required

Is your child's first-learned or home language anything other than English? *

Yes

If you resonded yes to the question above, please answer the following questions. *

What language did your child learn when he/she first began to talk? *

What language does your child most frequently speak at home? *

What language do you most frequently speak to your child? *

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