Advanced Learner Teacher and/or Parent Referral
We appreciate that you are taking the time to complete this form.

Some of the questions you will be required to answer are general contact information. Other questions will require you to provide information on each of the five areas of Gifted and Talented abilities.

These five areas are General Intellectual Ability, Specific Academic, Creativity, Leadership, and Visual and Performing Arts.

Please see the Advanced Learner (GT) Department website for additional information: www.sdb.k12.wi.us/advancedlearner

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Student Last Name     *
Student First Name     *
GRADE *
School *
Teacher Name (First & Last) *
Teacher Email *
Parent Name (First & Last) *
Parent Email *
Parent Contact Numbers *
Person Completing Form (First & Last Name) *
Person Completing Form (Email Address) *
General Intellectual Ability - Understands complex concepts
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Draws inferences between content areas
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Thrives on new or complex ideas
Strongly Disagee
Strongly Agree
Clear selection
General Intellectual Ability - Enjoys hypothesizing
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Intuitively knows before being taught
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Uses an extensive vocabulary
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Does in-depth investigations
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Learns rapidly in comparison to peers
Strongly Disagree
Strongly Agree
Clear selection
General Intellectual Ability - Additional Information
Specific Academic - Discusses and elaborates in detail
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Reads and comprehends on an advanced level
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Retains and retrieves information easily
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Masters and shows high level thinking in a specific content area
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Challenges teacher/parent to go further in depth and complexity
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Asks poignant questions
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Has a large vocabluary
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Connects and uses mathematical language and skills in meaningful real-world ways
Strongly Disagree
Strongly Agree
Clear selection
Specific Academic - Additional Information
Creativity - Questions, explores, experiments
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Asks unusual, provocative questions
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Is curious. Asks how, why, and what if?
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Risk taker
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Enjoys doing things in new ways
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Puts unrelated ideas and materials together in new and different ways
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Offers unique responses
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Has an active imagination (likes to pretend)
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Assumes another persona during activities or conversations
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Has trouble distinguishing fact from fiction
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Does not follow or wait for directions (makes own rules)
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Refuses to follow rules unless they see "why"
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Is seen as "deviant" or non-conformist
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Develops and tells elaborate "stories"
Strongly Disagree
Strongly Agree
Clear selection
Creativity - Additional Information  
Leadership - Organizes materials and activities
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Accepts and carries out responsibilities
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Is sought by others (influences others, positively or negatively)
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Adapts readily to new situations and changes
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Is a positive and compassionate guide to others
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Prefers adult company
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Is seen as manipulative and strong-willed
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Is seen as "bossy" (wants to be the center of attention)
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Dominates others (may not be a good follower)
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Makes strong contributions to community
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Sees a need and takes responsibility to fill a role within a group
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Perceives subtle differences in how people respond to change and conflict
Strongly Disagree
Strongly Agree
Clear selection
Leadership - Demonstrates an ability to communicate ideas with confidence
Strongly Disagree
Strongly Agree
Clear selection
Leadership: Additional Information
Visual/Performing Arts - (Music) Is keenly aware of sounds and listens with focused concentration
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Senses small differences in melodies, rhythms, sounds - recognizes patters
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Discriminates rhythmic differences and physically responds to rhythm in a fluid manner
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Discriminates differences in pitch and demonstrates a high level of tonal memory/audiation
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Extends, manipulates, and experiments with sound or movement
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Spontaneously and creatively responds to the aesthetic qualities of music
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Is eager and imaginative in expressing shaping an refining musical ideas
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Works thoroughly and perceptively in revising musical ideas
Strongly Disagrees
Strongly Agrees
Clear selection
Visual/Performing Arts - (Music) Performs with a fluid sense of rhythmic pulse and/or keen awareness of pitch, tone, melody, and hormony
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Works to improve performance capabilities through focused attention and skill practice
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Projects advanced musical expression beyond age or grade level
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Applies knowledge and skills to created musical compositions
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - (Music) Show persistence and persistence in musical tasks
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Is a keen observer (spots details others miss)
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Recognizes patters
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Creates interesting shapes and patterns
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Prefers hand-on experiences to learn
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Self-motivated and works well independently in artistic activities
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Consistently performs at a high level
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Shows imagination in presentation
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Draws/designs images from memory and/or imagination that show higher level creativity and/or realism
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Enjoys spending free time creating or analyzing art
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Uses other ideas to create their own unique materials as opposed to copying/recreating
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Art (Visual Arts) - Draws/designs with a high level of detail and skill
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Uses a variety of colors, values, sizes, textures, and shapes for desired effects
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Quickly grasps art instruction and applies it to own work  
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts (Visual Arts) - Shows high sentivitie to art and media
Strongly Disagree
Strongly Agree
Clear selection
Visual/Performing Arts - Additional Information
Please email Kristy Champion to let her know when you have completed this form.  kchampion@sdb.k12.wi.us
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This form was created inside of School District of Beloit.