ETHNIC/LANGUAGE GROUP DESIGNATION FORM

Student’s Name ______Date: ______

Please complete the following sections. This information is confidential and will be used in compiling reports required by the state and federal government and is valuable to the District.

Father/Guardian Information Mother/Guardian Information

Please circle one of the following parent education level: Please circle one of the following parent education level:

G = Graduate school/post graduate training G = Graduate school/post graduate training

C = College graduate C = College graduate

S = Some college S = Some college

H = High school graduate H = High school graduate

N = Not a high school graduate N = Not a high school graduate

D = Declined to State or Unknown D = Declined to State or Unknown

Please answer both parts of the following question per Federal ethnicity collection requirements

Is this student Hispanic or Latino? ¨ Yes

Please continue to answer the following by marking one or more boxes to indicate what you consider your ethnicity(s)/race(s).

ETHNICITY/RACE

/ ETHNICITY/RACE / ETHNICITY/RACE
American Indian/Alaskan Native / Hmong / Samoan
Asian Indian / Japanese / Tahitian
Black/African American / Korean / Vietnamese
Cambodian / Laotian / White
Chinese / Native Hawaiian
Filipino/Filipino American / Other Asian
Guamanian / Other Pacific Islander

Please check ONLY “1” BOX for your child’s home language in the following sections:

LANGUAGE NAME

/ LANGUAGE NAME / LANGUAGE NAME

5115.1 E-1 Rev 12/08

English / Hebrew / Pilipino ( Tagalog)
Albanian / Hindi / Polish
American Sign Language / Hmong / Portuguese
Arabic / Hungarian / Punjabi
Armenian / Ilocano / Rumanian
Assyrian / Indonesian / Russian
Burmese / Italian / Samoan
Cantonese / Japanese / Serbo-Croatian (Serbian)
Cebuano (Visayan) / Khmer (Cambodian) / Spanish
Chaldean / Khmu / Taiwanese
Chamorro (Guamanian) / Korean / Thai
Chaozhou (Chaochow) / Kurdish / Tigrinya
Croatian / Lahu / Toishanese
Dutch / Lao / Tongan
Farsi (Persian) / Mandarin (Putonghua) / Turkish
French / Marshallese / Ukrainian
German / Mien (Yao) / Urdu
Greek / Mixteco / Vietnamese
Gujarati / Pashto / Other Non-English Language

5115.1 E-1 Rev 12/08

5115.1 E-1 Rev 12/08