Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
Allen Himmelberger
Superintendent of Schools
David Thompson.Ed.D.
Assistant Superintendent
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
Home Language Survey - English
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in
order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other
than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the
following questions. Thank you for your assistance.
Student Information
First Name
Middle Name
Country of Birth
/
/
Date of Birth (mm/dd/yyyy)
F
Gender
Last Name
M
/
/
Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
/
/20
______
Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian)
What language did your child first understand and speak?
seldom / sometimes / often / always
Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
Which languages does your child use? (circle one)
speak / read / write
seldom / sometimes / often / always
speak / read / write
Will you require written information from school in your native
language?
Y
N
Parent/Guardian Signature:
seldom / sometimes / often / always
Will you require an interpreter/translator at Parent-Teacher meetings?
Y
N
/
Today’s Date:
X
/20
(mm/dd/yyyy)
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
Circle one:
Principal
Assistant Principal Guidance
FWHMS
Admin Assistant
Sign: ________________________________________________
BMRHS
ESL Teacher
Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
Home Language Survey - Spanish
Allen Himmelberger
Superintendent of Schools
.
David Thompson.Ed.D.
Assistant Superintendent
Encuesta del idioma hablado en el hogar
Los reglamentos del Departamento de Educación Primaria y Secundaria de Massachusetts exigen que todas las escuelas determinen los idiomas que se hablan en
los hogares de los estudiantes para así identificar sus necesidades específicas relacionadas con el idioma. Esta información es esencial para que las escuelas
puedan proveer instrucción que todos los estudiantes puedan aprovechar. Si en su hogar se habla otro idioma que no sea inglés, se requiere que el Distrito evalúe a
su hijo más a fondo. Ayúdenos a cumplir con este importante requisito respondiendo a las siguientes preguntas. Gracias por su ayuda.
Información del estudiante
Nombre
Segundo nombre
País de nacimiento
/
/
Fecha de nacimiento (mm/dd/aaaa)
F
Sexo
Apellido
M
/
/
Fecha de matriculación inicial en
CUALQUIER escuela de EE.UU. (mm/dd/aaaa)
Información de la escuela
/
/20
______
Fecha de comienzo en la escuela nueva (mm/dd/aaaa)
Nombre de la escuela y ciudad anterior
Grado actual
Preguntas para los padres/encargados
¿Cuál es el idioma natal del padre/la madre/los encargados? (encierre en
un círculo)
¿Qué idioma(s) se habla(n) con su hijo?
(incluya parientes -abuelos, tíos, tías, etc. - y encargados del cuidado)
infrecuentemente / algunas veces /
(madre / padre / encargado)
frecuentemente / siempre
(madre / padre / encargado)
infrecuentemente / algunas veces /
frecuentemente / siempre
¿Cuál fue el primer idioma que entendió y habló su hijo?
¿Qué idioma usa usted principalmente con su hijo?
¿Qué otros idiomas sabe su hijo? (encierre en un círculo todo lo que
corresponda)
habla / lee / escribe
¿Qué idiomas usa su hijo? (encierre uno en un círculo)
habla / lee / escribe
¿Requerirá usted la información impresa de la escuela en su idioma
natal?
Sí
No
Firma del padre/la madre/encargado:
X
infrecuentemente / algunas veces /
frecuentemente / siempre
infrecuentemente / algunas veces /
frecuentemente / siempre
¿Requerirá usted un intérprete/traductor en reuniones de padres y
maestros?
Sí
No
/
Fecha de hoy:
/20
(mm/dd/aaaa)
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
FWHMS
BMRHS
Circle one:
Principal
Assistant Principal
Guidance
Admin Assistant
ESL Teacher
Sign: ________________________________________________ Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
Allen Himmelberger
Superintendent of Schools
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
David Thompson.Ed.D.
Assistant Superintendent
Home Language Survey - English
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in
order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other
than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the
following questions. Thank you for your assistance.
Student Information
First Name
Middle Name
Country of Birth
/
/
Date of Birth (mm/dd/yyyy)
F
Gender
Last Name
M
/
/
Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
/
/20
______
Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian)
What language did your child first understand and speak?
seldom / sometimes / often / always
Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
Which languages does your child use? (circle one)
speak / read / write
seldom / sometimes / often / always
speak / read / write
Will you require written information from school in your native
language?
Y
N
Parent/Guardian Signature:
seldom / sometimes / often / always
Will you require an interpreter/translator at Parent-Teacher meetings?
Y
N
/
Today’s Date:
X
/20
(mm/dd/yyyy)
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
Circle one:
Principal
Assistant Principal Guidance
FWHMS
Admin Assistant
Sign: ________________________________________________
BMRHS
ESL Teacher
Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
Allen Himmelberger
Superintendent of Schools
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
David Thompson.Ed.D.
Assistant Superintendent
Home Language Survey - Portuguese
Pesquisa de idioma doméstico
Os regulamentos do departamento de Educação Elementar e Secundária de Massachusetts exigem que todas as escolas determinem os idiomas falados no domicílio de cada aluno
para identificar suas necessidades de idioma específicas. Essa informação é essencial para que as escolas ofereçam instrução significativa para todos os alunos. Se outro idioma que
não seja inglês for falado em casa, o distrito precisará realizar uma avaliação mais detalhada do seu filho. Por gentileza, ajude-nos a atender esse requisito importante, respondendo às
seguintes perguntas. Agradecemos a sua ajuda.
Informações do aluno
Nome
Nome do meio
País de nascimento
/
/
Data de nascimento (mm/dd/aaaa)
F
Sexo
Sobrenome
M
/
/
Data do primeiro registro em QUALQUER
escola norte americana (mm/dd/aaaa)
Informações da escola
/
/20
______
Data de início na nova escola (mm/dd/aaaa)
Nome da escola e cidade antiga
Grau escolar atual
Perguntas para os pais/tutores
Quais são os idiomas nativos de cada pai/tutor? (circule uma)
Quais idiomas são falados com seu filho?
(inclua parentes -avós, tios, tias, etc. - e babás)
(mãe / pai / tutor)
(mãe / pai / tutor)
Qual foi o primeiro idioma que seu filho compreendeu e falou?
Quais são os outros idiomas que seu filho conhece? (circule todas as
opções aplicáveis)
pouca frequência / algumas vezes /
com frequência / sempre
pouca frequência / algumas vezes /
com frequência / sempre
Qual idioma você usa com mais frequência com seu filho?
Quais são os idiomas que seu filho usa? (circule uma)
pouca frequência / algumas vezes /
com frequência / sempre
fala / lê / escreve
fala / lê / escreve
Você deseja receber informações por escrito da escola em seu idioma
nativo?
S
N
Assinatura dos pais/tutores:
pouca frequência / algumas vezes /
com frequência / sempre
Você deseja um intérprete/tradutor presente nas reuniões entre paisprofessores?
S
N
/
/20
Data de hoje:
(mm/dd/aaaa)
X
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
FWHMS
BMRHS
Circle one:
Principal
Assistant Principal
Guidance
Admin Assistant
ESL Teacher
Sign: ________________________________________________ Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
Allen Himmelberger
Superintendent of Schools
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
David Thompson.Ed.D.
Assistant Superintendent
Home Language Survey - English
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in
order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other
than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the
following questions. Thank you for your assistance.
Student Information
First Name
Middle Name
Country of Birth
/
/
Date of Birth (mm/dd/yyyy)
F
Gender
Last Name
M
/
/
Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
/
/20
______
Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian)
What language did your child first understand and speak?
seldom / sometimes / often / always
Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
Which languages does your child use? (circle one)
speak / read / write
seldom / sometimes / often / always
speak / read / write
Will you require written information from school in your native
language?
Y
N
Parent/Guardian Signature:
seldom / sometimes / often / always
Will you require an interpreter/translator at Parent-Teacher meetings?
Y
N
/
Today’s Date:
X
/20
(mm/dd/yyyy)
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
Circle one:
Principal
Assistant Principal Guidance
FWHMS
Admin Assistant
Sign: ________________________________________________
BMRHS
ESL Teacher
Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
‫‪Blackstone-Millville Regional School District‬‬
‫‪Allen Himmelberger‬‬
‫‪Superintendent of Schools‬‬
‫‪Department of Student Services‬‬
‫…‪“Minimizing Obstacles, Maximizing Opportunities‬‬
‫”!‪For Every Student‬‬
‫‪175 Lincoln Street‬‬
‫‪Blackstone, Massachusetts 01504‬‬
‫‪PHONE: (508) 876-0104‬‬
‫‪FAX: (508) 883-9892‬‬
‫‪David Thompson.Ed.D.‬‬
‫‪Assistant Superintendent‬‬
‫‪Home Language Survey - Arabic‬‬
‫استطالع رأي عن اللغة المستخدمة بالمنازل‬
‫تلزم لوائح إدارة التعليم االبتدائي والثانوي بوالية ماساتشوستس المدارس التابعة لھا بتحديد اللغة )اللغات( التي يستخدمھا الطالب في منازلھم وذلك بغرض تحديد احتياجاتھم‬
‫اللغوية الخاصة‪ .‬وتعد ھذه المعلومات بالغة األھمية للمدارس حيث ترتكز عليھا في توفير إرشادات ھامة للطلبة المسجلين بھا‪ .‬ففي حالة استخدام لغة أخرى غير اإلنجليزية في‬
‫المنزل‪ ,‬سيكون لزامًا على المنطقة إخضاع الطفل لمزيد من التقييم‪ .‬لذا الرجاء مساعدتنا في استيفاء تلك المتطلبات المھمة بإجابتك على األسئلة التالية‪ :‬ونشكركم على حسن‬
‫تعاونكم‪.‬‬
‫بيانات الطالب‬
‫االسم األوسط‬
‫االسم األول‬
‫‪/‬‬
‫محل الميالد‬
‫ذكر‬
‫النوع‬
‫اسم العائلة‬
‫‪/‬‬
‫‪/‬‬
‫تاريخ الميالد )الشھر‪/‬اليوم‪/‬السنة(‬
‫أنثى‬
‫‪/‬‬
‫تاريخ أول التحاق بأي مدرسة بالواليات المتحدة )الشھر‪/‬اليوم‪/‬السنة(‬
‫بيانات المدرسة‬
‫‪______ 20 /‬‬
‫‪/‬‬
‫تاريخ البدء في المدرسة الجديدة )الشھر‪/‬اليوم‪/‬السنة(‬
‫الصف الدراسي الحالي‬
‫اسم المدرسة السابقة والمدينة‬
‫أسئلة لآلباء‪/‬األوصياء‬
‫ما اللغة )اللغات( التي ُتستخدم مع الطفل؟‬
‫ما ھي اللغة )اللغات(األم للوالد‪/‬الوصي؟ )ضع دائرة واحدة(‬
‫)بما في ذلك األقارب واألجداد واألعمام واألخوال والعمات والخاالت ‪...‬إلخ‪،‬‬
‫ومقدمي الرعاية لألطفال(‬
‫)األم ‪ /‬األب ‪ /‬الوصي(‬
‫نادرً ا ‪ /‬أحيا ًنا ‪ /‬غالبًا ‪ /‬دائمًا‬
‫)األم ‪ /‬األب ‪ /‬الوصي(‬
‫نادرً ا ‪ /‬أحيا ًنا ‪ /‬غالبًا ‪ /‬دائمًا‬
‫ما ھي أول لغة فھمھا طفلك وتحدث بھا؟‬
‫ما ھي اللغة التي يكثر استخدامھا مع طفلك؟‬
‫ما ھي اللغات األخرى التي يعرفھا طفلك؟ )ضع دائرة على كل ما ينطبق عليه(‬
‫محادثة ‪ /‬قراءة ‪ /‬كتابة‬
‫ما ھي اللغات األخرى التي يعرفھا طفلك؟ )ضع دائرة واحدة(‬
‫نادرً ا ‪ /‬أحيا ًنا ‪ /‬غالبًا ‪ /‬دائمًا‬
‫نادرً ا ‪ /‬أحيا ًنا ‪ /‬غالبًا ‪ /‬دائمًا‬
‫محادثة ‪ /‬قراءة ‪ /‬كتابة‬
‫ھل تحتاج إلى مترجم فوري‪/‬تحريري أثناء اجتماعات اآلباء مع المدرسين؟‬
‫ھل تحتاج إلى معلومات مكتوبة من المدرسة بلغتك األم؟‬
‫نعم‬
‫نعم‬
‫ال‬
‫توقيع الوالد‪/‬الوصي‪:‬‬
‫‪X‬‬
‫التاريخ‪:‬‬
‫ال‬
‫‪20 /‬‬
‫‪/‬‬
‫)الشھر‪/‬اليوم‪/‬السنة(‬
‫‪For person administering Home Language Survey only:‬‬
‫‪BMRHS‬‬
‫‪ESL Teacher‬‬
‫‪FWHMS‬‬
‫‪AFM‬‬
‫‪Admin Assistant‬‬
‫__________________‪Date:‬‬
‫‪MES‬‬
‫‪Preschool‬‬
‫‪Circle one:‬‬
‫‪JFK‬‬
‫‪Assistant Principal Guidance‬‬
‫‪Principal‬‬
‫‪Circle one:‬‬
‫________________________________________________ ‪Sign:‬‬
‫‪The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation‬‬
‫‪or disability.‬‬
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
Allen Himmelberger
Superintendent of Schools
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
David Thompson.Ed.D.
Assistant Superintendent
Home Language Survey - English
Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in
order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students. If a language other
than English is spoken in the home, the District is required to do further assessment of your child. Please help us meet this important requirement by answering the
following questions. Thank you for your assistance.
Student Information
First Name
Middle Name
Country of Birth
/
/
Date of Birth (mm/dd/yyyy)
F
Gender
Last Name
M
/
/
Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
/
/20
______
Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians
What is the native language(s) of each parent/guardian? (circle one)
Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian)
What language did your child first understand and speak?
seldom / sometimes / often / always
Which language do you use most with your child?
Which other languages does your child know? (circle all that apply)
Which languages does your child use? (circle one)
speak / read / write
seldom / sometimes / often / always
speak / read / write
Will you require written information from school in your native
language?
Y
N
Parent/Guardian Signature:
seldom / sometimes / often / always
Will you require an interpreter/translator at Parent-Teacher meetings?
Y
N
/
Today’s Date:
X
/20
(mm/dd/yyyy)
For person administering Home Language Survey only:
Circle one:
Preschool
MES
JFK
AFM
Circle one:
Principal
Assistant Principal Guidance
FWHMS
Admin Assistant
Sign: ________________________________________________
BMRHS
ESL Teacher
Date:__________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.
Blackstone-Millville Regional School District
Department of Student Services
“Minimizing Obstacles, Maximizing Opportunities…
For Every Student!”
175 Lincoln Street
Blackstone, Massachusetts 01504
PHONE: (508) 876-0104
FAX: (508) 883-9892
Allen Himmelberger
Superintendent of Schools
David Thompson.Ed.D.
Assistant Superintendent
Home Language Survey - French
Enquête sur les langues parlées à la maison
Le règlement du Massachusetts Department of Elementary and Secondary Education exige que toutes les écoles déterminent la ou les langues parlées au domicile
de chaque élève afin d’établir ses besoins particuliers en matière de langue. Cette information est essentielle pour que les écoles puissent offrir un enseignement de
qualité à tous les élèves. Si une langue autre que l’anglais est parlée à la maison, le District doit évaluer davantage votre enfant. Veuillez nous aider à répondre à
cette exigence importante en répondant aux questions suivantes. Merci pour votre aide.
Renseignements sur l’élève
Prénom
Second prénom
Pays de naissance
/
/
Date de naissance (mm/jj/aaaa)
F
Genre
Nom
M
/
/
Date de la première inscription dans
une école américaine (mm/jj/aaaa)
Renseignements sur l’école
/
/20
______
Date de commencement dans la
nouvelle école (mm/jj/aaaa)
Nom de l’ancienne école et de la ville
Année actuelle
Questions pour les parents/tuteurs
Quelle est la langue maternelle de chacun des parents/tuteurs?
(encerclez une réponse)
(mère / père / tuteur)
Quelle(s) langue(s) parlez-vous avec votre enfant?
(y compris les membres de la famille – grands-parents, oncles, tantes, etc. – et
parents substituts)
rarement / parfois / souvent / toujours
(mère / père / tuteur)
rarement / parfois / souvent / toujours
Quelle langue votre enfant a-t-il apprise et parlée en premier?
Quelle langue utilisez-vous le plus souvent avec votre enfant?
Quelles autres langues votre enfant connaît-il?
(encerclez toutes les réponses applicables)
Quelles langues votre enfant utilise-t-il? (encerclez une réponse)
rarement / parfois / souvent / toujours
parlée / lue / écrite
rarement / parfois / souvent / toujours
parlée / lue / écrite
Avez-vous besoin de renseignements écrits de l’école dans votre langue
maternelle?
Oui
Non
Signature du parent/tuteur :
X
Você deseja um intérprete/tradutor presente nas reuniões entre paisprofessores?
Oui
Non
/
/20
Date d’aujourd’hui :
(mm/jj/aaaa)
For person administering Home Language Survey only:
Circle one: Preschool
MES
JFK
AFM
FWHMS
BMRHS
Circle one: Principal
Assistant Principal Guidance
Admin Assistant
ESL Teacher
Sign: ________________________________________________ Date:_________________
The Blackstone-Millville Regional School District does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation
or disability.