Early Learning Screening

Grundy County Special Education IN-PERSON Early Learning Screening

Minooka Primary Center

March 20, 2021
Student Name *

First Name Middle Name Last Name
Student Birthdate *

Month Day Year
Date
Age
Student Gender *
Date

Month Day Year
Date
Ethnic Background *
Student Primary Language *

English Spanish
What languages are spoken in your home?
Student Birthplace (City / State) *

Street Address

Street Address Line 2

City State / Province
Primary Guardian / Mother's Name *

First Name Last Name
Occupation *
Highest Level of Education Completed: *
Mother's Maiden Name
Secondary Guardian / Father's Name

First Name Last Name
Occupation
Highest Level of Education Completed:
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number *
E-mail *
All communication will occur via email.
Resident District *
Appointment *
Thank you for your interest in the GCSEC Screening Process, however, we only accept appointments for students who will be between 3 and 6 years of age at the time of screening.