Chardon Local School District

Home Language Survey

Date: Grade: Building:

Name:
Last Name First Name Middle Initial
Date of Birth: Sex Place of Birth:
Month Day Year City State Country
Name of Parent/Guardian:
Home Address
City: State: Zip Code:
Home Phone: Work Phone:

For Parents/Guardians – Please answer the following questions:

1. What language did your son/daughter speak when he/she first learned to talk?
2. List all languages spoken in the home. Circle language used most frequently when speaking to your child.

3. Circle the people in your home who speak a language other than English.
Father Mother Grandmother Grandfather Aunt Uncle Cousins Caregiver None
4. What language does your son/daughter use most frequently at home?
5. What language do you use most frequently to your son/daughter?
6. What language do the adults at home most often speak?
7. What is the parent’s native language? Mother Father
8. Which parent speaks English? Mother Father
9. Which parent reads English? Mother Father
10. Is an Interpreter needed? Yes No
11. How long has your son/daughter attended school in the United States?
12. Father’s Name Mother’s Name
13. List brother/sisters
Name Birthdate School

14. List all schools student attended in the U.S.

Name of School Location-City & State Dates attended Grades

Signature Date