Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs.  This information is essential in order for schools to provide meaningful instruction for all students.  If a language other than English is spoken in the home, the District is required to do further assessment of your child.  Please help us meet this important requirement by answering the following questions.  Thank you for your assistance.

Student Information

First Name _______________________________

Middle Name _______________________________

Last Name _______________________________

Gender     F   M

Country of Birth _______________________________

Date of Birth (mm/dd/yyyy)  _____­­­_ /______ /______

Date first enrolled in ANY US school  _____­­­_ /______ /______ 

School Information

Start Date in New School  _____­­­_ /______ /______

Name of Former School and Town _______________________________

Current Grade __________

 
Questions for Parents/Guardians

What is the native language(s) of each parent/guardian? (circle one)

______________________ (mother / father / guardian)

______________________ (mother / father / guardian)

 
Which language(s) are spoken with your child?
(include relatives, grandparents, uncles, aunts, etc.)

__________________  seldom/sometimes/often/always

__________________  seldom/sometimes/often/always

 
What language did your child first understand and speak?

 
Which language do you use most with your child?

Which other languages does your child know?(circle all that apply)

____________________________ speak / read / write

____________________________ speak / read / write

 
Which languages does your child use? (circle one) 

_____________________ seldom/ sometimes/ often/ always

_____________________ seldom/ sometimes/ often/ always
 
Will you require written information from school in a language other than English? ____ (YES)  ____ (NO)

Will you require an interpreter/translator at Parent Teacher meetings? ____ (YES)  ____ (NO)

 
Parent/Guardian Signature:

X________________________________

 
Today’s Date:

______ / ______ / ______