Text Box: Student Referral for Gifted Program Evaluation-W Text Box: Name of Student ______________________________________________ Date of birth ___________ Address _________________________________________________________ Phone _____________ Parent(s) Name __________________________________ / ___________________________________ Email addresse(s) _________________________________ / _________________________________ Name of Person Completing this Referral Form _________________________________ Relationship to student ____________________________________________________ Springfield School of Attendance ___________________________________ Grade ___________ School currently attending (if private, parochial or home-schooled) _____________________________ Is student transferring or moving from another school district? ______ Has student been grade advanced? ______ If yes, what grade / school year? __________ Text Box: For Office Use: Date Rec’d. __________ student # ______________

SECTION  1  Student Information
Text Box: This student is making application to be evaluated for gifted services. As a part of the process, classroom teachers are requested to complete the scale below. Rate this applicant on the following characteristics using 1= low to 5 = high: Personal Development ____ Focuses on tasks ____ Works well independently ____ Seeks help when needed ____ Shows pride in effort ____ Evaluates own work Social Development ____ Works cooperatively in a small group ____ Works cooperatively in a large group ____ Works without interrupting the learning of others ____ Tries to resolve conflicts appropriately ____ Accepts responsibility for own actions ____ TOTAL Signature of Teacher ___________________________________ Date ___________ School _____________________________ District ________________________

SECTION  2  To be completed by classroom teacher

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