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Home Language Survey Date Student s Name Male Female Date of Birth Age Grade What language is spoken in your home most of the time What language does the student speak most of the time Has the student received English as a Second Language services in previous schools Yes No If yes when and where services last received Year School Signature of Parent/Guardian FOR ESL OFFICE USE ONLY Date Rec in ESL office LEP Category Date of LAS test Test Results ESL Program services/School.
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