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Gifted Referral
If you suspect that a student is gifted, please complete this form.
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* Indicates required question
Email
*
Your email
Your LAST Name:
*
Your answer
Your FIRST Name:
*
Your answer
Relationship to Student:
*
Your answer
Student LAST Name:
*
Your answer
Student FIRST Name:
*
Your answer
Student ID Number
Your answer
Student's Current Grade Level
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Kindergarten
First grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
Homeroom Teacher's Name
*
Your answer
Student's date of birth?
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MM
/
DD
/
YYYY
Area of suspected gifted identification:
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Superior Cognitive Ability
Math Ability
Reading/Writing Ability
Science Ability
Social Studies Ability
For any other suspected gifted area contact the Gifted Services Coordinator
Why do you suspect the child is gifted? Please provide some evidence or explanation below.
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Your answer
List any medical or other conditions or circumstances that may be impacting student’s academic performance and/or ability to perform well on standardized testing.
*
Your answer
What is a primary email address for correspondence?
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Your answer
Do you have a secondary email address for correspondence?
Your answer
If this is a parent or guardian referral, do we have your permission to send test results through email?
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Yes
No
NA
If this is a parent or guardian, do we have your permission to assess your child using ODE approved assessments for gifted identification?
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Yes
No
NA
Any other information you feel would be helpful to determine identification.
*
Your answer
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