Home Language Survey - Norwalk Public Schools

Norwalk Public Schools
Home Language Survey
As per State Department Regulations, this form is to be completed upon registration of all children entering the Norwalk
Public Schools. ONE COPY MUST be kept in the student’s PERMANENT RECORD FILE. If a language other than
English is indicated, another copy must be given to the BILINGUAL/ESOL teacher in the building immediately.
Name/Nombre_______________________________Date/Fecha____________________
School/Escuela_________________________________Grade/Grado________________
Address/Dirección_________________________________________________________
Telephone/Teléfono___________________________Parent/Padre__________________
Country & Date of Birth/Lugar & Fecha de Nacimiento _________________________________
Date of first entry into a U.S. school/ Fecha de entrada a alguna escuela en los Estados Unidos:
______________________________________________________________________________________
English
1. What is the first language that the student learned to speak first? ________________________________
2. What is the primary language spoken by the student’s parents, guardians or other persons where the student lives?
___________________________________________________________________________
3. What is the primary language spoken by the student when he or she is home? __________________
Spanish
1.¿Qué idioma aprendió primero su niño(a)?__________________________________________________
2.¿En qué idioma le habla usted a su niño(a) en casa?__________________________________________
3.¿Qué idioma habla su niño(a) en casa? ___________________________________________________
Italian
1. Quale e stata la prima lingua che vostro figlio/a ha imparato de parleare? _________________________
2. In che lingua parlata a vostro figlio/a in casa? ________________________________________________
3. Che lingua parla vostro figlio/a in casa? ____________________________________________________
Greek
1.
2.
?__________________________________________________________________
3.?_________________________________
Haitian Creole
1. Ki premye langue elev la aprann ?_________________________________________________________
2. Ki langue paran elev la pale et tout moun nan kay la pale?______________________________________
3. Ki langue elev la pale kan li la kay?________________________________________________________