GT Parent Permission to Collect Data & Parent Info

Russellville School District - Gifted & Talented Office
Dana Sumter, GT Coordinator
2203 S. Knoxville, Russellville, AR  72802
Phone: 479-968-3106    
Email: dana.sumter@rsdk12.net
 
All information on this form will be kept strictly confidential and will be used only by GT program personnel and the appropriate referral/placement committee.
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Email *
Student Name *
Student Date of Birth *
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School Building *
Current Grade *
Teacher's Name *
Parent/Guardian Name *
Home Address *
Parent Phone Numbers (Home/Work) *
PERMISSION FOR GT SCREENING  --  I grant the Russellville School District permission to include my child in the pool of students to be screened for participation in Russellville's Gifted and Talented Program. Furthermore, I grant permission for RSD GT personnel to gather education data on my child and to administer the screening instruments currently being used for GT identification purposes. By typing my name below and submitting this form I give my consent. *
A copy of your responses will be emailed to the address you provided.
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