For office use: date rec’d ________ student # ______

10/09

Phelps Center for Gifted Education Student Referral =

Name of student_________________________________________= __ Grade ____ Birth date ___________

Address __________________________________________ Zip _________ Home phone ______________

Parent/Guardian Name(s) ________________________________= __________ Work phone ______________

Par= ent’s cell phone _______________________/________________________

Par= ent’s email address _____________________________________________

Sch= ool ____________________________________ Teacher ____________________= _________________

New to SPS district?&nb= sp; Y / N Previous gifted program= ? Y / N Grade advanced? Y / N Which grade? _________=

Observation Checklist

5 – almost always 4 – consid= erably 3 – occasionally 2 – seldom 1 – never

_____ &= nbsp; 1. Has unusually advanced vocabulary for age or grade level<= /p>

_____ 2. Stores a= large amount of information on a variety of topics

_____ 3. Has quick mastery and recall of factual information

_____ 4. Has rapid insight into cause-effect relationship….tries to discover the how and= why of things

_____ 5. Has a re= ady grasp of underlying principles and can quickly make valid generalizations

_____ &n= bsp; 6. Is a keen and alert observer, usually “sees more” or “gets more” out of a story, book or film

_____ &n= bsp; 7. Reads a great deal on his/her own, usually prefers adult level book

_____ &n= bsp; 8. Becomes absorbed or very involved in certain topics or problems<= /span>

_____ &n= bsp; 9. Needs little external motivation to follow through in work that initially excites him/her

_____ 10. Strives toward perfection; is self-critical; is not easily satisfied wi= th his/her own speed or products

_____ 11. Prefers to work independently; requires little direction from teachers<= o:p>

_____ 12. Often is self assertive (sometimes even aggressive); stubborn in his/her beliefs

_____ 13. Is quite concerned with right and wrong, good and bad; evaluates events, people, or things

_____ 14. Displays a great deal of curiosity about many things<= /p>

_____ 15. Generates a large number of ideas or solutions to problems and question= s

_____ 16. Is a high risk taker; adventurous and speculative

_____= 17. Displays a good deal of intellectual playfulness; fantasizes; imagines R= 20;I wonder what would happen if….”

_____ 18. Displays a keen sense of humor and sees humor in situations that may not appear to others

Do y= ou have any personal/social development concerns about this child? __________________________________________

____= ___________________________________________________________________________= ______________________

Signature of p= erson completing form ___________________________________ Relationship to child _______________ D= ate _________

Please return completed form to:

The Phelps Center for Gifted Education

934 S. Kimbrough - Springfield, MO&= nbsp; 65806

Phone 417-523-3300 – Fax417-523-3395

http://sps.k12.mo.us/phelps

……&#= 8230;…………………………= …………………………̷= 0;…………………………= 230;…………………………&= #8230;……………………

For office use = &nb= sp; = &nb= sp; = &nb= sp;

= &nb= sp; = &nb= sp; = &nb= sp; = = &nb= sp; = &nb= sp; = date rec’d _________

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = = student # _________