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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Student Information
Last Name *
First Name *
School *
Present Grade *
Birthplace *
If birthplace is other than the U.S., please list student's date of entry in the U.S. *
Date of Birth *
MM
/
DD
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YYYY
Age *
Home Phone *
Residence
Address *
City *
State *
Zip Code *
Parent Information
Father's Name *
Father's Birthplace *
Mother's Name *
Mother's Birthplace *
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
Was the child exited from an English Language Program? *
If Yes, indicate when?
Do you think the child will benefit from an English Language Program (ESL) *
Signature
Signature of Person Completing Survey *
Relationship to Student *
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