August 11 2018 Early Learning Screening

Grundy County Special Education Early Learning Screening - February 9th, 2019

Minooka Elementary School, 400 W Coady Dr., Minooka, IL 60447

Student Name *

First Name Middle Name Last Name

Student Birthdate *

Date

Student Gender *

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
Postal / Zip Code	Country

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	State / Province
Postal / Zip Code	Country

Phone Number *

E-mail *

All communication will occur via email.

Resident District *

Appointment Time Slots *

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.

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