HOME LANGUAGE SURVEY (applies to all students entering Kindergarten AND new students to Christ The Lord)
School District of Elmbrook, 13780 Hope Street PO Box 1830, Brookfield WI 53008-1830.
Please complete this form. 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.
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* Required
Student Information
Last Name
*
Your answer
First Name
*
Your answer
School
*
Christ the Lord Lutheran, Brookfield WI
Other:
Present Grade
*
Choose
K
1
2
3
4
5
6
7
8
Birthplace
*
Your answer
If birthplace is other than the U.S., please list student's date of entry in the U.S.
*
N/A
Other:
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Home Phone
*
Your answer
Residence
Address
*
Your answer
City
*
Your answer
State
*
WI
Other:
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?
*
English
Other:
Languages Spoken at Home
What language do the parents speak with other adults in the home?
*
English
Other:
What language does the parent(s) speak to her/his child most of the time?
*
English
Other:
What language does the child speak to her/his parent(s) most of the time?
*
English
Other:
What language does the child speak to her/his friends outside of school?
*
English
Other:
Does an adult in the home speak English?
*
Yes
No
Does an adult in the home read English?
*
Yes
No
English Language (ESL) Support
Was the child ever enrolled in an English Language Program (ESL)?
*
Yes
No
If Yes, indicate school name
Your answer
Was the child exited from an English Language Program?
*
Yes
No
If Yes, indicate when?
Your answer
Do you think the child will benefit from an English Language Program (ESL)
*
Yes
No
Signature
Signature of Person Completing Survey
*
Your answer
Relationship to Student
*
Your answer
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