HOME LANGUAGE SURVEY
ELL (English Language Learner)
PARENT PERMISSION FORM
Because district personnel are often unaware that ELL students are in their schools, the MDE (Mississippi Department of Education) strongly recommends that home language information be obtained at the time the student first registers for school. This information should be obtained for all students, including Native American students who may need language development services.
Student Name (Please Print):
Please answer the following questions:
1. What language do YOU MOST OFTEN use when speaking to your child?
2. What language did YOU FIRST learn to speak?
3. What language DOES YOUR CHILD MOST OFTEN use when speaking to brothers, sisters, and other children at home?
4. What language DOES YOUR CHILD MOST OFTEN use when speaking to you and other adults in the home?
5. What language DOES YOUR CHILD MOST OFTEN use when speaking to friends or neighbors OUTSIDE the home?
Please return this form to your homeroom teacher.
HOMEROOM TEACHER: If You have observed a problem with this student’s command of the English language, please indicate by checking the appropriate response: _____YES _____NO
HOMEROOM TEACHER SIGNATURE DATE
PARENT/GUARDIAN SIGNATURE DATE
PRINCIPAL’S SIGNATURE/PRINCIPAL’S DESIGNEE DATE