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I A V :h< E = F rlr 5 AT d n 6'5 F 9' gE T F O = e.' tE o A v ( g 2a frl is xE F ) = : ' = R i. o 0 a z o FluvannaCountyPublicSchools HomeLanguageRegistrationForm Theinformationon this form mustbe collectedon all studentswho registerin FluvannaCountyPublicSchools.All informationmust be collectedfrom parentsandguardiansin their nativelanguageif they areunableto reador speakin English. This form meets irementsof the Equal Educational ty Act20 USC 1703for identificationof nationalorigin minority children. STUDENT: First Dateof Birth Middle Age _ Grade School Month/date/year 1. Is thereanyonein your homewho speaksa languageotherthanEnglish? YES 2. Wherewasthe studentborn? UnitedStates NO kircle one) OtherCountry: A. last grade completed in native country B , DatestudententeredU.S. C. Circle all gradescompletedin U.S. schools: None Pre-K K | 2 3 4 5 6 7 8 9 l0 ll 12 D. DatestudententeredVA schools E. Studentis : 3. Hasthe studenteverreceivedESL or ESOLservices? Ifyes, Dates YES immigrant _ NO migrant _refugee Not Sure SchoolDistrict/State English Spanish French Russian Other:(specifl') 4. Whatwasthe first languagethe student learnedto speak? 5. Whatlanguagedoesthe studentspeak at home? 6. Whatlanguageis mostoftenspoken at home? 7. What language(s)do adults speak at home? The lm,vrequires that all language minority children be screenedto determine English languageproficiency for acqdemicsuccessin school. Screening takes approximately one hour or less, and you will be notified of the results. 8. Do you give permission for your child to be screened to determine English language proficiency? Signatureof Parent/Guardian Printed Name of Parent/Guardian _YES _ NO Date TelephoneNumber SchoolRegistrar: A copy ofthe HLR form must be sent to your ELL coordinatorimmediately. (Revised10/2008) Distribution: Orisinal-Cum.Folder/ESOL Copy: SchoolLEP Coord./ESL District Office (Espanolen ladotrasero) Las Escuelas Ptiblicas del Gondado de Fluvanna Documento de Solicitud Para ldioma Hablado en Gasa sobreestaformase debeconseguir La informaci6n de todoslosestudiantes matriculados en escuelasp0blicasdelcondado Todala informaci6n se debeconseguir de Fluvanna. de padresy de guardas en su lenguamaterna si no puedenleero hablar ingl6s.Estaformacumplerequisitos del actoeducativo de la oportunidad igual20 USC'1703parala identificacion de los nifrosminoritarios delorigennacional. Nombredelestudiante: Grado:_ Escuela: Fechade nacimiento: mes/fecha/afro persona 1. lHaycualquier en su hogarquehableunalenguaconexcepcion de ingl6s? Si No (Elijauno) naci6el estudiante? 2. s,D6nde _Estados Unidos _El otropais: A. Grado reci6ncompletadoen pais nativo B. Fechade la entradadelestudiante en losEstados Unidos C . C e r q u e t o d looss g r a d o s c o m p l e t a d eo s ceune l a s dl oesE . E . U . U . : N i n g u n oPsr e - KK 1 2 3 4 5 6 7 I 9 1 0 1 1 1 2 D. Fechade entradaa las escuelasde Virginia E. El estudiante es:_inmigrante _migratorio _refugiado servicios delESLo de ESOL?Si No Incierto(Elijauno) Si si, Fechas 3. 4,Harecibido el estudiante escolar/estado Ingl6s Espafrol Franc6s Ruso Distrito Otro: (especifioue) 4. a,Cu(tl erael primer idiomaqueel aprendio a estudiante hablar? 5 . a Q u ei d i o m ah a b l ae l estudianteen casa 6 . ; Q u e i d i o m as e hablalo m6s en casa? 7. aQue idiomashablan los adultosen casa? paraaveriguar quetodoslosnifiosminatorios cu5les su conocimiento delidioma de la lenguaseanevaluados La leyrequiere y notificaran hora o menos, le a Ud.de para la aproximadamente una en escuela. El examen toma el exito acad6mico ingles losresultados. quesu nifioseaevaluado paraaveriguar de ingl6s? Si cu5les su conocimiento 8. iDa Ud.el permiso Firmadelpadre/delguarda Nombreimpresodel padre/delguarda No(Elijauno) Fecha, Nimerode tel6fono immediately. A copyof theHLRformmustbe sentto yourELLcoordinator SchoolRegistrar: Folder/ESOL Copy:SchoolLEPCoord./ESL District on otherside) Original-Cum. Office (English Distribution: