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HOME LANGUAGE SURVEY

Bentworth School District

Home Language Survey

Date:*

Answer Required

School:*

Answer Required

Bentworth Elementary School

Bentworth Middle School

Bentworth High School

Student's Legal First Name*

Answer Required

Student's Legal Middle Name

Answer Required

Student's Legal Last Name*

Answer Required

Date of Birth*

Answer Required

Grade:*

Answer Required

What is the student's first language?*

Answer Required

Does the student speak a language other than English?*

Answer Required

YES

If the student does speak a language other than English, please specify the languages:

Answer Required

Has the student attended any schools in the United States during any three year span during his/her lifetime?*

Answer Required

YES

If "Yes", please provide the following information:

Name of school, State and dates attended

Answer Required

Person completing this form:*

Answer Required

Signature:*

Answer Required

The school district has the responsibility under federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school district has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district may conduct screenings or ask for related information about students who are already enrolled in the school as well as from students who enroll in the school district in the future.