ROCKBROOK ELEMENTARY

SCHOOL

1200
Avenue

Merritt

Lewinsdale, Pennsylvania 15931

Part of the Hanover Area School District
HOME LANGUAGE SURVEY
Family Name:
Student Name:
Age:

Birthdate:

Present Grade Level:

Place of Birth:

Homeroom:

Homeroom Teacher:

Father/Guardian Name:
Mother/Guardian Name:
Address:
Phone Number: HOME (

)-

MOBILE (

)-

WORK (

Email Address:
Please list all other children in the household.
Student
Name

Birthdat
e

Birthpla
ce

Ag
e

Grad
e
Level

School
Attending

Language
Spoken

1. Do you need a translator? If so, what language?

Yes (PLEASE SPEFICY LANGUAGE)
No
Language Preference: __________________________________________
2. What is the best way to contact you? Please check all that apply.
Phone
Written
E-mail
Conference

)-

Language Preference: __________________________________________

3. What was your childs first language?
___________________________________________
4. Does your child speak a language other than English? (LANGUAGES
LEARNED IN LANGUAGE COURSES DO NOT COUNT.)
Yes (PLEASE SPEFICY LANGUAGE)
No
5. What language is primarily spoken in the home?
___________________________________________
6. Has your child attended a school in the United States within the past five
years?
Yes
No
If yes, please specify the school name, location, and how long your child
attended.
School Name

Location (City, State)

How long attended?

(EX: August 2012-May
2013)

7. Can your child read in English?

Yes
No
8. Can your child write in English?
Yes
No
9. Can your child read in your home language (other than English)?
Yes
No
10. Can your child write in your home language (other than English)?
Yes
No

11. Can a parent/guardian or other adult family member read in English?

Yes
No

12. Can a parent/guardian or other adult family member write in English?

Yes
No
13. Can a parent/guardian or other adult family member read in your home
language (other than English)?
Yes
No
14. Can a parent/guardian or other adult family member write in your home
language (other than English)?
Yes
No
15. Are you interested in participating in family activities at the school?
Yes
No
If you answered yes, please specify which activities you would be interested
in and we will send you the information regarding those activities.
Scholastic Book Fair
Box Tops/Campbells Soup
Labels
Holiday Program
Class Parties

Family Bingo
Family Luncheon
Field Trip Chaperone
Market Day

Please list some of your childs interests (ex: superheroes, Spongebob,

Disney Princesses) and hobbies (ex: reading, dancing, building).

____________________________________________
____________________________________________
Parent/Guardian Signature
(PRINTED)

____________________________________________
____________________________________________
Parent/Guardian Signature
(PRINTED)

Parent/Guardian Name

Parent/Guardian Name