MELL Program Parent Survey

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If you have moved from one school district to another and you have worked in an agriculturally based employment in the last three (3) years, then your child may be eligible for special services to better serve his or her educational needs. Please complete the following survey information.

Parent or Guardian's last name *

Parent or Guardian's first name *

Have you moved to this area in the past three (3) years *

Yes

In the last three (3) years, have you worked or are you currently working in any of the following fields? *

Yes

Check all that apply

Planting or harvesting fruits, vegetables, flowers

Transporting farm products to market

Feeding poultry, gathering eggs, working in a hatchery

Processing meat, poultry, fruit, vegetables, dairy products

Milking cows on a dairy farm

Working on a sod farm

Commercial fishing or working on a fish farm

Growing and tending trees to be sold

If you checked any of the boxes above, did you move to seek or obtain that job?

Yes

Clear selection

Home address: *

Phone number: *

Student's name *

Grade *

Student's name

Grade

Student's name

Grade

Student's name

Grade

Student's name

Grade

Student's name

Grade

Submit

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