oHCHSnKRC West Contra Costa Unified School District _________________________ ______________________ _________ vGnTE} kansxlvdkanIz{PasaY}IUnb{an oHCHSn glkh{RC #

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zQ}KRCnGkHSn:_______________________________________________________________ ________ ________ _______ zQ} nansAkun zQ}kaC/zQ}n{Ry zG{nHSn Rayu gPd

1. Xm}nPasahyGCTE}lUkzayLQlUksavKRCT}anHSngvJ{aIngmQ}RlavglE}mHSngvJ{agTQ}RTxRed? ___________________________________________ 2. Xm}nPasahyGCTE}lUkzayLQlUksavKRCT}angvJ{aLayk}vaM}UY}UInb{anKRCT}an? ___________________________________________ 3. Xm}nPasahyGCTE}T}angvJ{aLayk}vaM}UYU}Inb{anKRCT}an? ___________________________________________ 4. Xm}nPasahyGCTE}PvkB{IUhy}gvJ{aLayk}vaM}UY}UInb{anKRCT}an? ___________________________________________

____________________________ laygzGnKRCPO}Xm}LQBU{pJkcRC

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5. kAlunaKSnvGngdQRnpEgkEdXlApAgTdTE}KRClUkT}angkEd: ________________ pAgTdTE}id{gkEd: ______________________ vGngdQRnpEgkEd (sxlGbh{RCkanKRCoHCHSn: If the country of birth is not the US, send copy of HLS to RAP Center even if English is the only language listed.) [State of California, Department of Education OPER - LS 77 R-6/70] TaCoHCHSn WCCUSD Ih{T}antRbcxDamcG{Clu}mnE{gPQ}Rz}vyPvkgHJaInkansxlvdnE{gPQ}RjAid{z}vyInkanHSnlUkKRCT}an:

k. lUkzayLQlUkyeCKRCT}anid{gKJ{aoHCHSnY}UgTdRQ}nbO}? ____ ____ D{aid{gKJ{a, gKJ{aid{jGkpE ________________________________________ Id{gKJ{a bO}id{gKJ{a

K. lUkzayLQlUksavKRCT}anid{gKJ{aoHCHSnY}UsAharGdRAgmrekabO}? ____ ____ D{aid{gKJ{a, Xm}ngmQ}RId ____/____ Y}UIs}? ___________, ____ ____________ Id{gKJ}a bO}id{gKJ}a gdQRn/ pE gmQRC rGD zQ}KRCoHCHSn

c. lUkzayLQlUksavKRCT}anid{gKJ{aoHCHSnY}U WCCUSD magmQ}Rk}RnbO}?________ ________ D{agcEyid{gKJ{a, Xm}ngmQ}RId? _____ /_____ gcEyid{gKJ{a bO}gcEyid{gKJ{a gdQRn pE [EL Services -- WCCUSD -- ns -- Revised 3/11/10] Attention school office: Retain original in cum folder --- Send copy to ELS, RAP Center, ONLY if it lists a language other than English OR the country of birth is not the U.S. (or both).

LAO – WCCUSD Translation Revision by ELS - Chris Karnsouvong 3/11/10