BILINGUAL PROGRAM HOME LANGUAGE SURVEY FOR

BILINGUAL PROGRAM HOME LANGUAGE SURVEY FOR

W-APT LEVEL
ACCESS ENG. PROF. LEVEL
OFFICE OF BILINGUAL MULTICULTURAL EDUCATION
BILINGUAL PROGRAM
HOME LANGUAGE SURVEY FOR ENGLISH LANGAUGE LEARNERS
(Parent Permission/Refusal)
ENTRY DATE IN U.S.
School
RE-ENTRY DATE
Date
STUDENT’S INFORMATION:
M F
Student’s Last Name
First
MI
Student’s Address
Telephone
Attendance Area School
Years Previous Schooling
Previous School
Address
(Circle Sex)
ID Number
Grade
(I-94)
English
Bil
Only
ESL
Programs at Previous School
Spanish
Only
Special
Education
ALIEN REGISTRATION NUMBER
To be filled out only if student has refugee status
Learning
Difficulties
Last Grade Completed
Mexican
Puerto Rican
Hmong
Student’s Ethnic Background
Student’s Place of Birth
Birth date
Father’s, Guardian’s or Sponsor’s Name
Address
Telephone
Mother’s, Guardian’s or Sponsor’s Name
Address
Telephone
Other
LANGUAGE INFORMATION:
What language did the student learn first?
Spanish
English
Other
What language does he/she speak most often?
Spanish
English
Other
What language is most often spoken in his/her home?
Spanish
English
All
What language does the mother/father/guardian
speak most often?
Spanish
English
Eng. w/other
Optional: Additional Information:
NOTE: THIS FORM MUST BE SIGNED BY PARENT, GUARDIAN OR SPONSOR.
Parent/Guardian/Sponsor Signature
MPS Staff Collecting This Information
Date
Revised 9/09
BILINGUAL PROGRAM CONSENT/REFUSAL FORM
TO BE FILLED OUT AND SIGNED BY PARENT, GUARDIAN, OR SPONSOR:
I am aware that my child IS OR IS NOT an English Language Learner (ELL) and eligible for receiving bilingual instruction. I
have been informed in my dominant language of the benefits regarding these services to my child. I understand that the goals of
the Bilingual Education Program of Milwaukee Public Schools are to help students develop their English and Spanish language
skills and to progress through the regular school curriculum using both languages.
At this time I prefer that my child,
be enrolled in the Bilingual/Bicultural Program at this school, if available.
be transferred to a school where he/she will receive Bilingual/Bicultural education. Transportation to and from school
may be provided according to Transportation guidelines.
not be enrolled in the Bilingual Program at this or any other school. He/She will be part of the monolingual English
program.
be enrolled at an ESL Stand Alone program.
be enrolled in this school’s monolingual program, because I understand he/she is not eligible for the Bilingual Program.
Parent or Guardian’s Signature
Date
FORMULARIO DE CONSENTIMIENTO/REHUSAMIENTO PARA EL PROGRAMA BILINGÜE
PARA SER LLENADO Y FIRMADO POR EL PADRE, GUARDIAN O ENCARGADO:
Entiendo que mi hijo/hija ES o NO ES un estudiante que aprende inglés (ELL) y elegible para recibir educación bilingüe. Se
me ha informado en mi propio idioma de los beneficios que estos servicios aportarían a mi hijo/hija. Entiendo que los objetivos
del Programa de Educación Bilingüe de las Escuelas Públicas de Milwaukee es ayudar al estudiante a desarrollar sus destrezas
lingüísticas en español e ingles y a progresar a través del programa escolar utilizando ambos idiomas.
Por el presente prefiero que mi hijo/hija,
sea inscrito(a) en el Programa Bilingüe/Bicultural de esta escuela si está disponible.
sea transferido(a) a otra escuela en donde pueda recibir educación bilingüe/bicultural. Se podría ofrecer servicios de
transporte, de conformidad a los reglamentos de transporte.
no sea inscrito(a) en el programa Bilingüe de esta ni de ninguna otra escuela. El/Ella ingresara en el programa monolingüe
en ingles de esta escuela.
sea inscrito(a) en un programa de Inglés como segundo idioma.
sea inscrito(a) en el programa monolingüe de esta escuela porque no es elegible por el Programa Bilingüe/Bicultural.
Firma del padre, madre, o encargado
Fecha