View Black River Local Schools
Gifted Referral Form-Please print off and fill out, turn in to building administrator.

Referred by:

¨ Parent

¨ Teacher

¨ Student

¨ Other

 

(Title)

 

Black River Local Schools

Nomination for Gifted Identification and Academic Acceleration

 

 

Student:

 

Date:

 

 

School:

 

Class of:

 

Current Grade:

 

 

 

 

 

 

 

Signature of Person Initiating Referral

 

Position or Relationship to Student

 

Date

 

 

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

Notes:

 

 

¨ Early Entrance to Kindergarten

 

 

¨ Grade Acceleration

 

 

¨ Subject Acceleration

 

 

¨ Early Graduation

 

 

           

 

 

Parent/Guardian Name:

 

 

Address:

 

Phone:

 

Cell:

 

         

 

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.

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