Custer
Public
Schools
Home Language Survey
Student Name
required
Birth Date
required
today
Sex
required
Male
Female
Parent/Guardian Name
required
Parent/Guardian Email
required
Address
required
Home Telephone
required
Work Telephone
School
required
Grade
required
Today's Date
required
today
Was your child born in the United States?
required
Yes
No
If yes, which State
If no, in what other country?
Has your child attended any school in the United States for any three years during their lifetime?
required
Yes
No
If yes, please provide the school name(s), state, and dates attended
Name of School
required
State
required
Dates Attended
required
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Add School
What language is spoken by you and your family most of the time at home?
required
If available, in what language would you prefer to receive communication from the school?
required
Please check if your child is
Native American Indian
Alaska Native
Native Pacific Islander
Native U.S. Virgin Islander
Is your child's first-learned or home language anything other than English?
required
Yes
No
If you responded yes to the question above, please answer the following questions
What language did your child learn when he/she first began to talk?
What language does your child most frequently speak at home?
What language do you most frequently speak to your child?
Parent/Guardian Signature
required
Clear
Date Signed
required
today
Submit
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