Lakeside School District Gifted Referral
Please answer all questions to the best of your ability in regards to the student that is being referred.
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Email *
Your Name *
Student's Name *
Student's Grade *
What is your role? (in relation to the student) *
Please choose the number rating for each item using the scale listed below.
Scale: 0=Never 1=Seldom 2=Occasional 3=Often 4= Almost Always
General Ability *
0
1
2
3
4
Has a large or advanced vocabulary for age
Has a rapid recall of information
Learns easily and quickly in novel situations
Possess a lot of information about a variety of subjects
is inquisitive; asks unusual or higher level questions
Generates several solutions or alternatives to a problem or situation
Defends ideas, using reasoning and logical argument
Responds to injustice with objection, or questions rules
Specific Ability *
0
1
2
3
4
Has superior verbal reasoning ability
Has superior numerical reasoning ability
Generates original ideas in writing or expression
Can focus and become absorbed in topics of interest
Can combine seemingly unrelated ideas or concepts into a more specialized area of knowledge or performance
Task Commitment *
0
1
2
3
4
Displays persistence in task completion, especially in areas of interest
Strives towards perfection; is self-critical
Works independently in areas of interest and at the time, requires little direction from the teacher
Creativity *
0
1
2
3
4
Is a high risk taker with ideas; speculates on outcomes, changes and differences
Discovers one example that is the exception to the rule
Displays originality of thought
Receptive to what is new and different
Leadership Ability *
0
1
2
3
4
Is self-confident with peers and adults
Demonstrates a willingness for and skills in decision making
Exhibits organizational skills with tasks, peers, time, and/or materials
Carries responsibility well and works well in situations that require initiative and independence
Shows empathy and tolerance toward others; generally relates well with others
Can express self well; has good verbal skills and is usually well understood
Please explain why you feel the student needs these services beyond the regular classroom. *
Please state your full legal name as a signature certifying your responses. *
A copy of your responses will be emailed to the address you provided.
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