HOME LANGUAGE SURVEY
School District of Elmbrook, 13780 Hope Street PO Box 1830, Brookfield WI 53008-1830.

The School District of Elmbrook is required to survey all students. The purpose of this Home Language survey is to ensure that no child in the United States is denied an opportunity to be successful in school due to limited English proficiency.

Please complete this form if your child is a new student (Kindergarten through Grade 8) attending Christ the Lord.

STUDENT INFORMATION
Last Name *
Your answer
First Name *
Your answer
Present Grade *
School *
Birthplace
Your answer
City *
Your answer
State *
Date of Birth *
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Age *
Your answer
Phone (include area code) *
Your answer
If birthplace is other than the U.S., please list student's date of entry in the U.S. *
Residence
Street Address *
Your answer
City
Your answer
State *
Zip Code
Your answer
Parent Information
Father's Name *
Your answer
Father's Birthplace *
Your answer
Mother's Name *
Your answer
Mother's Birthplace *
Your answer
Please check the correct boxes
What language did the child learn when he/she first began to talk? *
Languages Spoken at Home
What language do the parents speak with other adults in the home? *
What language does the parent(s) speak to her/his child most of the time? *
What language does the child speak to her/his parent(s) most of the time? *
What language does the child speak to her/his friends outside of school? *
Does an adult in the home speak English? *
Does an adult in the home read English? *
English Language (ESL) Support
Was the child ever enrolled in an English Language Program (ESL)? *
If Yes, indicate school name
Your answer
Was the child exited from an English Language Program?
If Yes, indicate when?
Your answer
Do you think the child will benefit from an English Language Program (ESL)
Signature
Signature of Person Completing Survey *
Your answer
Relationship to Student *
Your answer
Today's Date *
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