Gifted Program Referral Form 23-24

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Please submit this form if you would like to refer a student for possible identification for the K-5 Gifted Program.

Email *

School Site *

Name of Person Initiating Referral *

What is your phone number or extension? *

I am this student's (check one): *

Teacher

Parent

Legal Guardian

Other:

Required

Student Name (First and Last) *

Student Perm ID Number (Please do not leave this blank or write "unknown." Thank you!) *

Student Birthday (Please do not leave this blank or write "unknown." Thank you!) *

Student Grade Level *

Name of Classroom Teacher *

Room # *

Please mark all appropriate boxes below: *

Student is an English Learner (SEI Classroom or ILLP)

Student is enrolled in Special Education (IEP)

Student has a 504 Plan

Student receives grade level academic intervention

Student was previously identified for gifted services or program in another district/state

Student exceeds grade level expectations

Student has been accelerated (grade-skipped) one or more grades (not subjects)

Student started kindergarten before age 5 (early entrance)

None of the above

Unknown

Other:

Required

Name of Parent/Guardian(s) *

Email of Parent/Guardian(s) *

Phone number of Parent/Guardian(s) *

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This form was created inside of Santa Cruz Valley USD No. 35.

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