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St. Sebastian Regional Catholic School 2022-2023

Home Language Survey

 


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.

First Parent/Guardian Name

First Name*

Last Name*

Phone*
First Parent/Guardian Age Acknowledgment*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Last Name*
Second Parent/Guardian Date of Birth*
Third Parent/Guardian Name

First Name*

Last Name*
Third Parent/Guardian Date of Birth*
Fourth Parent/Guardian Name

First Name*

Last Name*
Fourth Parent/Guardian Date of Birth*
Fifth Parent/Guardian Name

First Name*

Last Name*
Fifth Parent/Guardian Date of Birth*
Sixth Parent/Guardian Name

First Name*

Last Name*
Sixth Parent/Guardian Date of Birth*
Seventh Parent/Guardian Name

First Name*

Last Name*
Seventh Parent/Guardian Date of Birth*
Eighth Parent/Guardian Name

First Name*

Last Name*
Eighth Parent/Guardian Date of Birth*
Ninth Parent/Guardian Name

First Name*

Last Name*
Ninth Parent/Guardian Date of Birth*
Tenth Parent/Guardian Name

First Name*

Last Name*
Tenth Parent/Guardian Date of Birth*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Student Information

Full Name (First / Middle / Last) *

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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
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. 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.


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