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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