Guiding Academically Talented Exceptional Students

New Richmond Exempted Village School District

Gifted Education Program

Parent/Teacher Referral Form for Gifted Identification

Completed forms should be returned to Mrs. Vicky Phillips, Gifted Coordinator

Student ____________________ Grade __ School ___________ Teacher ________________

Address _________________________ Zip ________ Phone ___________ Date __________

                                                                                    Reason for Referral

Superior Cognitive Ability                            ____________________________________

                                                                        ____________________________________

Specific Academic Area

o Reading/Writing                          ____________________________________

o Math                                             ____________________________________

o Science (Grade 2+)                    ____________________________________

o Social Studies (Grade 2+)         ____________________________________

Creative Thinking                                          ____________________________________

Visual and Performing Arts

o Art                                                 ____________________________________

o Music                                            ____________________________________

o Dance                                           ____________________________________

o Drama                                          ____________________________________

Subject or grade acceleration                     ____________________________________

                                                                        ____________________________________

o Subject                                         __________ from grade ___ to grade ______

o Grade                                           Current grade ___________ to grade ______

___________________________________________________                             _________

Signature of person initiating referral and relationship to student                                   Date

___________________________________________________                             _________

Parent signature (Required for testing)                                                                       Date