GELA Registration & Developmental Screening Form
Welcome to GELA
Please complete this pre-registration form to be considered for our infant and toddler full-time or part-time programs. Once your application has been carefully reviewed, a member of the GELA team will personally contact you regarding acceptance or next steps. We look forward to learning more about your family and welcoming you into the GELA community.
General Information
Parent #1 Name
*
First Name
Last Name
Parent #2 Name
First Name
Last Name
Child's Name
*
First Name
Middle Name
Last Name
Child's Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2026
2025
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Year
Child's Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Primary E-mail
*
example@example.com
Secondary E-mail
(optional)
Parent #1 Primary Phone Number
*
Format: (000) 000-0000.
Parent #2 Primary Phone Number
*
Format: (000) 000-0000.
Preferred Start Date:
*
-
Month
-
Day
Year
Date
Preferred Care Schedule
*
Please Select
Full Time 5 days a week
Half Days Full Time- 5 days a week
Half Days Part-Time- 3 days a week (T-TH)
We're Flexible
Emergency Contact Name: Non Parents
*
First Name
Last Name
Emergency Contact relationship to child
*
Emergency Contact #; if Parent #1/2 are unavailable
*
Format: (000) 000-0000.
Primary Language Spoken at Home
*
Secondary Language Spoken at Home
(optional)
Has your child attended childcare, preschool, or early learning programs before?
YES, FULL-TIME
YES, PART-TIME
NO, NOT AT ALL
Other
If yes, please list program(s) and duration:
Please list the dates and name of center
Health & Medical Overview
Has your child ever received early intervention or special services?
*
Speech Therapy
Physical Therapy
Occupational Therapy
Vision Impaired Coaching
Behavioral Therapy- ABA
Mental Health Counseling
NO, none
Other
Does your child have any diagnosed medical conditions?
*
YES
NO
If yes, please explain:
Pediatrician Name
Exceptional Childcare Needs: Allergies (food, medication, environmental):
Additional Comments
If not full-time, please indicate preferred schedule.
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Developmental & Enrichment Screening (Quick Check)
Please check all that apply. This section helps us tailor enrichment and intervention support. It does not replace a formal evaluation.
Speech & Language Development
*
Uses age-appropriate words and sentences
Limited vocabulary for age
Difficulty expressing wants or needs
Speech is difficult to understand
Not yet combining words
Other
Hearing & Listening Skills
*
Responds when name is called
Follows simple verbal directions
Frequently asks for repetition
Appears not to hear consistently
History of ear infections or hearing concerns
Other
Developmental Milestones
*
Met milestones on time, based on pedeatrician exams
Delays in speech, motor, or social development
Difficulty with transitions or changes in routine
Needs additional support with self-help skills
Other
Autism-Related Traits (Observation-Based)
*
Makes eye contact appropriately
Engages in pretend or imaginative play
Prefers solitary play most of the time
Repetitive movements (hand flapping, rocking, spinning)
Strong reactions to sensory input (sound, texture, light)
Other
Motor Skills (Fine & Gross)
*
Walks, runs, and climbs with ease
Difficulty with balance or coordination
Challenges using crayons, scissors, or utensils
Low muscle tone or frequent fatigue
Other
Social & Emotional Development
*
Engages positively with peers
Difficulty sharing or taking turns
Frequent frustration or emotional outbursts
Responds well to adult guidance
Other
Strengths, Interests & Enrichment Areas
Please take your time and share specific details about your child. This section insight into your child to help motivate, engage, and support their growth.
What does your child enjoy or do well?
*
Areas where you would like enrichment or additional support:
*
Consent for Developmental Screenings & Referrals
This consent allows Granting Excellence Learning Academy to conduct informal/formal screenings, when appropriate to support your child’s development. Screenings are observational and do not constitute a medical diagnosis. By signing below, I give permission for my child to participate in:
Developmental screenings (speech, language, motor, social-emotional)
Progress monitoring for enrichment or intervention planning
Classroom-based observations for learning and behavioral support
Parent Partnership Agreement Contract Form
I understand that this program emphasizes collaboration between families and educators to support enrichment and early intervention.
I hereby sign to confirm I understand that: *Screenings are used solely to support my child’s educational growth *Results will be shared with me and discussed collaboratively *To decline or withdraw consent at any time in writing may impact my child's enrollment *Referrals may include early interventions, or therapists when appropriate
*
Print Parent/Guardian Names
Date
*
-
Month
-
Day
Year
Date
Signature
*
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