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Home Language Survey for Geibel 2018-19

This survey is used to determine a primary or home language other than English. Parents or guardians are asked to complete the following questions about the language use of your child. When appropriate, the child may answer the questions. Parents are not required to answer questions with regard to origin. However, even countries of origin whose primary language is English may have a dialect making it difficult for a child to understand American dialects.

Who will be signing?
AdultMinor
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First Parent/Guardian Name

First Name*

Last Name*

Phone*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Student Information

Full Name *

Date of Birth *

Age *
Grade*

Country of Student's Origin *

Other Countries of Residence (Please List)
What was the first language your child learned to speak?*
English
Other

Other
What language(s) does your child speak most often at home?*
English
Other

Other
What language(s) can your child read?*
English
Other

Other
What language(s) can your child write?*
English
Other

Other
What language(s) do you use when speaking to your child?*
English
Other

Other
What language(s) is spoken most often in your home?*
English
Other

Other
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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