Gifted and Talented Request

Elementary Phone: 419-736-2161 Middle School Phone: 419-736-3304 High School Phone: 419-736-3303

Gifted Referral Form-Please print off and fill out, turn in to building administrator.

Referred by:

¨ Parent

¨ Teacher

¨ Student

¨ Other




Black River Local Schools

Nomination for Gifted Identification and Academic Acceleration










Class of:


Current Grade:








Signature of Person Initiating Referral


Position or Relationship to Student





Area(s) for Referral

Reason(s) for Referral

This student is referred for possible

identification in the following area(s):

Check all that apply.

¨ Superior Cognitive Ability

¨ Mostly A’s on grade card

¨ Specific Academic Ability
Indicate specific subject(s):

¨ Unchallenged with regular curriculum

¨ Reading

¨ Asks/answers questions above and
beyond same age peers

¨ Writing

¨ Writes/creates using detail and originality

¨ Mathematics

¨ Enjoys studying and/or performing topics
out of school

¨ Science


Please be specific in describing your reason

for referring this student:


¨ Social Studies



¨ Creative Thinking Ability



¨ Visual or Performing Arts Ability:
drawing, painting, sculpting,

music, dance, drama




Academic Acceleration




¨ Early Entrance to Kindergarten



¨ Grade Acceleration



¨ Subject Acceleration



¨ Early Graduation






Parent/Guardian Name:











Signature of Parents: _________________________________________________DATE: ________________________


Gifted Consultant: ___________________________________________________DATE: __________________________

Distribute copies of this document to: building principal(s), current teacher, receiving teacher, gifted coordinator/GIS, and parent(s) or legal guardian(s).  Place a copy in the student’s file.