Clarke County Schools



Clarke County Schools

155 Cobb Street

Grove Hill, Alabama 36451

Home Language Survey

2010-2011

This form must be completed upon enrollment of any student. A form must be completed on each child in a family.

Date___________________School_____________________Grade____________________

Child’s Name_________________________________________________________________________

First Name Middle Initial Last Name

Parent or Guardian’s Name______________________________________________________________

First Name Middle Initial Last Name

Address______________________________________________________________________________

Street City State Zip

Phone Number__________________ _________________________________

Home Work

Date of Birth________________ Age_____________ Gender (male or female)___________

Social Security/I.D. Number________________________________

What date did the child enter the United States?_________________

In what country was student born?____________________________

What is the first language the student learned to speak? _____English ____Spanish _____Other

What language does the student speak most often? ______English _____Spanish _____Other

What language is most often spoken in the student’s home? ___English ___Spanish _____Other

In what language does the student read? _________English _______Spanish ________Other

In what language does the student’s parent(s) read? ______English ____Spanish ______Other

Signature____________________________________Date_____________________________

OFFICE USE ONLY

|Student ID# |Date Distributed |Date Received |

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