Highly Capable Program Referral Form
REFERRAL WINDOW IS CURRENTLY CLOSED

The Anacortes Highly Capable Program (HiCap) serves students K-12 who perform or show potential for performing at significantly advanced academic levels when compared with others of their age, experiences, or environments.

Please consider referring a student for HiCap if you believe they are performing or have the potential to perform significantly above grade level and may possess, but are not limited to, the following learning characteristics:
(1) Capacity to learn with unusual depth of understanding, to retain what has been learned, and to transfer learning to new situations;
(2) Capacity and willingness to deal with increasing levels of abstraction and complexity earlier than their chronological peers;
(3) Creative ability to make unusual connections among ideas and concepts;
(4) Ability to learn quickly in their area(s) of intellectual strength; and
(5) Capacity for intense concentration and/or focus.

Referral Process:
1. Complete the rating scale listed below. Enter the appropriate number for each statement using the range of:
1 = Never, 2 = Seldom, 3 = Occasionally, 4 = Often, 5 = Almost Always.

2. Complete the narrative box on the last page. This is your opportunity to tell the selection committee any information about the student that is not made evident in the rating scale or their academic test scores.

3. OPTIONAL: You may email or mail copies of up to 3 recent student work samples or student projects which demonstrate abilities that you observe (no originals please).
Please submit to: Highly Capable Program, wdurham@asd103.org or Wendy Durham 2200 M Avenue, WA 98221.
Email address *
Student Last Name *
Your answer
Student First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
School *
Your answer
Grade *
Your answer
Teacher *
Your answer
Relationship to Student *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone # *
Your answer
Parent/Guardian email address *
Your answer
Does the student have a special need or IEP/504 about which you would like to communicate to the committee? *
Does the student need an accommodation for their IEP/504? *
If a special need accommodation is needed, what services are required? *
Your answer
Learns Rapidly and Easily *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Has Intense Emotions *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Offers original, imaginative responses *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Easily Switches between home/school culture *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Is widely informed on many topics *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Understands concepts readily *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Has an independent nature *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Challenges the teacher's knowledge base *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Is inquisitive, skeptical *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Does not accept things at face value *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Extensive vocabulary (English or Home Language) *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Dislikes arbitrary decisions, keen sense of justice *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Constantly asks questions *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Strong sense of cultural pride *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Seeks out challenging work *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Produces original ideas and projects *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Shows interest in other cultures *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Uses logic to solve problems *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Has long attention span in areas of interest *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Is intrigued by abstract ideas *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Has an advanced sense of humor *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Eager to translate for peers or adults *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Is easily bored *
1=Never 2=Seldom 3=Occassionally 4=Often 5=Almost Always
Additional Comments *
Your answer
A copy of your responses will be emailed to the address you provided.
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