10435 Downsville Pike

Hagerstown, MD 21740
301-766-2800

Please respond
Educational History and Home Language Survey (English)
(The information on this form will be used to complete state and federal reports and improve services for your student)
in English.

Students Name
First Name Middle Name Last Name

Date of Birth School Grade

1) What is the students country of birth?

2) If born outside the USA, what is the students most recent entry date
to the USA (excluding visits/vacations)?

3) How many total years has the student attended school?

4) Since entering school, has the student ever missed more than six
consecutive months of formal schooling? Yes No

5) How many years has the student attended U.S. schools?

6) On what date the student first enroll in a US school?

7) What language did the student learn when he/she first began to talk?

Can the student read and write this language? Yes No

8) What language does the student most frequently use at home?

Mother:
9) What language do you most frequently speak to the student at Father:
home? Guardian:

10) Has the student ever been in an ELL/ESL/ESOL or a bilingual

program? Yes No

If so, how many years did the student attend the program?

If available, in what language would you prefer to receive communication from the
school?

Parent or Guardian Signature Date

Please distribute one copy to each:

Building a Community That Inspires Curiosity,
ELL School-based MemberCreativity, and Achievement.
ELL Department Central Office Students Cumulative File

www.wcps.k12.md.us