La Conner School District Highly Capable/Highly Motivated Program Referral
Please complete this form for a La Conner School District student whom you wish to refer for the Highly Capable/Highly Motivated (HiCap) program.

Please consider the following criteria in your referral:

Students referred should have demonstrated abilities in one or more of the following areas:

Specific academic achievement in one or more major content areas as demonstrated in results of achievement test appropriate to discriminate academic performance at high levels of achievement in one or more of the following content areas: reading, mathematics, social studies, language arts, and science. Students are generally in the top 10% in reading and/or math as measured by a standardized achievement test.

Exceptional cognitive ability, which includes such psychological concepts as thinking, abstract reasoning, problem solving, verbal comprehension, and numerical facility.

Exceptional creativity which, for this purpose, shall mean the demonstration of unique or outstanding creative products and/or the demonstration of unusual problem solving ability or other learning characteristics which may indicate that the student has the intellectual potential to perform academically at a level significantly higher than the norm for the chronological grade level.

Student Information
Please provide contact and student information.
Student Name
Your answer
Student Birthdate
MM
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DD
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YYYY
Current Grade:
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Home Mailing Address
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City, State, Zip
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Parent/Guardian Email Address
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Parent/Guardian Phone Number
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Support: Please describe the student’s capabilities in the following areas
In the space provided below, please explain why the student should be considered for Highly Capable Program services.
Your answer
Referral By
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Nomination Submitted By:
Your Name
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Relationship to Student
Contact information
Please provide contact information in case we need clarification or more information.
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