Home Language/ Pre- School Survey

Student’s Name: ____________________________ Teacher’s Name: ______________

School Year: ______________________

1. What language is spoken in your home most of the time? _________________
2. What language does the student speak most of the time?  _________________
3. What language do parents speak to the student most of the time? ____________

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ACT 472 4/28/95

Has your child been expelled from another school? _____YES     _____NO

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Is the Student eligible to participate in any of the following programs?

      1. Migrant _____Yes   _____No

      2. Homeless _____Yes _____No

      3. English as a Second Language _____Yes _____No

      4. Section 504 _____Yes _____No

      5. Speech _____Yes _____No

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If the student is a Special Education Student, is he/she Medicaid eligible?

 _____Yes _____No

If Yes, Please provide Medicaid Number _________________________

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Pre-School program attended before entering Kindergarten:

List any pre-school programs your child attended:

      Examples:  ABC, Early Childhood Program (at M.D.Primary), Head Start,

            Private Day School (such as Presbyterian Day School, Mary’s Little Lamb,  

            Ms. Betty’s Playschool, or any other day care.

            ________________________________________________________________  

            ________________________________________________________________

 _____ NONE

My child attended:   (Please check one)

20 hours or more per week _____

            Less than 20 hours pre week_____

School/Schools Attended before this one:

School name                                                    School address

1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________