Northern Local 2023-24 Parent Referral  Licking Regional ESC Referral and Permission for Gifted Evaluation
Referral and Permission for Gifted Evaluation
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Email *
Student First Name *
Student Last Name *
Student Date of Birth *
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Building *
Grade *
Please select your child's grade level
Homeroom *
Please list your child's homeroom.
Source of Gifted Referral *
Parent/Guardian First and Last Name *
Parent/Guardian Phone Number *
Street Address *
City *
Zip Code *
Area/s for Gifted Referral *
Please mark the area/s that you would like your child tested.  
Required
I request that my child be tested for gifted identification.  I understand that my child may be tested in one or more areas by a gifted coordinator, and that prior testing results will also be reviewed. *
I understand that my child may be given additional assessments based on the results of this evaluation. *
I understand that my child may be tested on any business-day within 90 days after the referral for gifted evaluation is received by the gifted coordinator. *
I understand that these testing results will be evaluated for potential placement in gifted services according to my district's placement policies and procedures. *
I will receive testing results within 30 days of the of the testing date.  I have the right to appeal these results. *
I understand that neither a parent referral, gifted testing, nor gifted identification guarantee my child a position in gifted services.  Space in gifted services is limited. *
Please indicate below if your child receives special services and already has a formal document outlining testing accommodations on file with the district.: *
By typing my name below, I give permission for my child to be testing. *
Equal access will be available to all students for screening, further assessment, identification, and placement in eligible services, including minority or disadvantaged students, students with disabilities, and students for whom English is a second language.
Relationship to Child *
Date *
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A copy of your responses will be emailed to the address you provided.
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