Home language survey

HOME LANGUAGE SURVEY

All students new to the district must have this survey completed and signed by a parent/guardian in accordance with state regulations (23 Illinois Administrative Code Part 228).

This information is used to count the students whose families speak a language other than English at home. It also helps to identify the students who need to be assessed for English language proficiency.

Student’s Last Name:

First :

Middle:

Gender:

MaleFemale

Student’s Last Name:

First:

Middle:

Gender:

MaleFemale

School:

SIS ID#:

Has your child attended a District 59 Preschool program?

YesNo

School

If you answered yes, do not continue as you have already completed this form upon entering Preschool. If you answered no, please proceed to answer the following questions below.

1.Is a language other than English spoken in your home?YesNo

What language?

2.Does your child speak a language other than English?YesNo

What language?

Parent/Guardian (Print)

Relationship to Student:

Date:

Parent/Guardian Signature: