Home Language Survey

For NEW studens only.

Required fields marked with an asterisk *

Upon enrollment, every student or parent/guardian must be given a Home Language Survey. This survey will be used to determine which students should be assessed for English proficiency. Knowledge of, or exposure to another language does not, in and of itself, qualify a student for ESOL services. If a language other than English is indicated in any of questions 1-4, the student will be assessed to determine eligibility for English or Speakers of Other Languages (ESOL) services. The assessments approved by the Kansas State Department of Education include: The Language Assessment Scales (LAS)/LAS LINKS/Pre-LAS, the IDEA Proficiency Test (IPT)/Pre-lPT, the Language Proficiency Test Series (LPTS), and the Kansas English Language Proficiency Assessment (KELPA)/KELPA-P. If a student scores below proficient/fluent in any of the language domains: listening, speaking, reading, or writing, s/he is eligible for ESOL services. Please complete one form for each child.

Student Information

First Name*

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Date first enrolled in a school in the U.S.A.*

Answer Required

Phone Number*

Number Required

Student Language Information

What language did your child first learn to speak/use?*

Answer Required

English

Spanish

Other:

What language does your child speak/use at home? Do NOT include language learned in a class or through television or other such programming.*

Answer Required

English

Spanish

Other:

What language do you speak/use with your child?*

Answer Required

English

Spanish

Other:

What language do the adults regularly present or living in the home speak/use while in the presence of the child?*

Answer Required

English

Spanish

Other:

Parnet/Guardian Information

What language do you prefer for written communication?*

Answer Required

English

Spanish

Other:

What language do you prefer for spoken communication?*

Answer Required

English

Spanish

Other:

To the extent practicable, communication from the school will be provided in this language.

Migrant Education Program Information:

The Migrant Education Program (MEP) is authorized by Title I Part C of the Elementary and Secondary Education Act of 1965 (ESEA). The MEP provides formula grants to local education agencies to establish or improve education programs for children who may qualify for the Migrant Program. Please help us determine your child's eligibility for the Migrant Program by responding to the following questions.

Has your family moved in the last 36 months to seek or obtain agriculture or fishing related work?*

Answer Required

YES

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Home Language Survey