Northshore School District Enrollment Form Page 4
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4STATE REQUIRED HOME LANGUAGE SURVEY — This is for the student
WAC392-160-005
Country of Birth ___________________________________________
City / State of Birth ________________________________________
Did your child receive English language development support through the Transitional Bilingual Instruction Program in the last school your
child attended? YES ________
NO ________
Don’t Know
1. What language did your child first learn to speak? __________________________
2. What language does YOUR CHILD use most at home? ______________________
3. What language(s) do parent/guardians use the most when you speak to your child? _______________________________
“First Language” is the language your child learned when first beginning to talk. If the answer to this question is a language other than English,
your student will be given a Washington State Language Proficiency Placement Test.
Complete A, B, and C below if student’s Country of Birth is other than the United States
★ ★ ★
★ ★ ★
A. _____________________
How many months has the student attended public school in the United States (grades K-12) prior to enrolling
in the Northshore School District?
B. _____________________
How many months has the student received formal education outside the United States in his/her native
language (equivalent to grades K-12) prior to enrolling in the Northshore School District?
C. _____________________
The date the student first enrolled in public education anywhere in the United States.
Guidance
One (1) school year = ten (10) months
“Formal education” does not include refugee camp schools or other unaccredited programs for children.
“Native Language” refers to the family’s dominant language.
PREVIOUS SCHOOL INFORMATION
(List most recently attended school first. All fields must be completed.)
#1 School Name ____________________________________________
Entry Date
_______________________________________
(mm/dd/yy)
District ________________________________________________
Withdrawal Date
__________________________________
(mm/dd/yy)
Address ________________________________________________
Grades attended ___________________________________________
City ___________________________________________________
State ______________________
Zip ____________________
#2 School Name ____________________________________________
Entry Date
_______________________________________
(mm/dd/yy)
District ________________________________________________
Withdrawal Date
__________________________________
(mm/dd/yy)
Address ________________________________________________
Grades attended ___________________________________________
City ___________________________________________________
State ______________________
Zip ____________________
#3 School Name ____________________________________________
Entry Date
_______________________________________
(mm/dd/yy)
District ________________________________________________
Withdrawal Date
__________________________________
(mm/dd/yy)
Address ________________________________________________
Grades attended ___________________________________________
City ___________________________________________________
State ______________________
Zip ____________________
Parent/Guardian Signature Required
_____________________________________________________________________
_____________________________________________
Parent / Guardian Signature
Today’s Date
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