Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 15, app A
Student Name: ___________________________ Birth Date: _____________ Gender: __Male __ Female
Parent/Guardian Name: _________________________________________________________________
Address: _____________________________________________________________________________
Home Telephone: _______________________ Work Telephone: _______________________________
School: _________________________________ Grade: _______ Date: _________________________
What language did your child first learn to speak? ___________________________________________
What language is spoken most often by your child? __________________________________________
What language is primarily used in the student's home regardless of the language spoken by the student?
Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 15, app A