Student Name: (Surname/Family Name) (First)   (Second Given Name)
Country of Birth:     Date of Birth: Grade:
Parent/Guardian Name(s):
Address: (Street) (City) Phone:
Number of years of previous schooling:
If student was not born in the U.S., provide date first enrolled in a U.S. school:

Federal and state regulations require schools to determine the language(s) spoken and understood by each student. This information is necessary for schools to provide appropriate instruction.

1. What language or languages did your child use when he/she first began to speak?
2. What language or languages does your child speak with you at home?
3. What language or languages do you (parents or guardians) use when you speak to your child?
4. Do the adults in your home (parents, guardians, grandparents or any other adults) speak to each other in a language other than English?   NO YES
  If yes, what language?

In what language do you prefer to receive school correspondence?

English Other, please specify:

 I understand that if my child first spoke a language other than English, or if another language other than English is spoken in the home, my child’s English language proficiency will be evaluated.

 Parent/Guardian Signature Date  

School History: Where did the student attend school for each grade?

Kindergarten Grade 1

Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Years of School Completed:

NOTE:   If there is another language other than English spoken at home, students will automatically be tested for English language development services.

Alternative Language Service



Dear Parent/Guardian:

Your student was identified as an English Language Learner through an individualized screening test for placement (WIDA Model) or by the end-

of-year ACCESS test to measure growth. Your student’s level of English proficiency is

  . The areas assessed to determine the proficiency level were reading, writing, speaking and listening. Mastery of English is ranked by five levels from Level 1—Entering to Level 5—Bridging. Once a student reaches a Level 5, he/she is exited from the program and monitored for four years to ensure that he/she continues to achieve academically. The average time to develop oral proficiency takes 3 to 5 years, and academic English proficiency can take 4 to 7 years.

Based on the testing results, your student is eligible to receive ESL (English as a Second Language) services at our school to help develop the oral and written English skills necessary to be successful in his/her classes. An ESL-endorsed teacher will provide the English language development instruction your student receives. This English instruction will be taught in addition to your student’s regular classes, and the ESL teacher will help your student learn strategies to better understand the Core Curriculum.


Your child will receive the following services:

WILL BE SERVED in an ESL class/classes for:

  • ≤ One period per day to provide English language development in reading, writing, speaking, and listening.
  • ≤ One period a day of sheltered instruction in a Core classroom.

WILL BE MONITORED—Your child’s academic classroom progress will be monitored. Support will be provided as needed.


Your child will be automatically scheduled for these services. If for some reason you prefer that your child not participate in the services noted above, please let us know at your earliest convenience. The alternative service will be to place your student on an Individual Language Development Plan. The Individual Language Development Plan requires the school to work with your student and his/her teachers to set language goals twice per year and monitor progress toward academic achievement and language proficiency. This plan




Alternative Language Services

Refusal of Services Form


To Whom It May Concern:

I request that my child not receive direct services in the Alternative Language Services programs. I understand that testing will continue until my son/daughter scores Fluent on Utah’s English language proficiency assessment, ACCESS for ELs. I understand that this refusal of services is valid only for the current school year and must be renewed each year.


Parent/Guardian Signature


Address Telephone Number


Principal/ALS Site Coordinator Signature Date


Alternative Language Services (ALS) Program

Parent Notification of Exit from ALS Program



Dear Parent/Guardian:

Your child has met the requirements to exit the Alternative Language Services (ALS) Program. He/she has demonstrated proficiency on the ACCESS for ELLs® test, which measures progress in English language acquisition. He/she will be monitored for four years after the exit date.

In the event that your child needs additional support, a team of educators will determine a plan of action that will best support your child. All options will be considered, including returning your child to Alternative Language Services, if needed.


If you have any questions, please contact .







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