Highly Capable Program Referral Form
The Burlington-Edison 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 on the next few pages by carefully considering the learning, motivational, and creativity characteristics of the student.  Circle 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 placement committee any information about the student that is not made evident in the rating scale or their academic test scores.

3. OPTIONAL: You may attach copies of up to 3 recent student work samples or student projects which demonstrate abilities that you observe.  Do not attach originals, as items will not be returned.

4. Submit Referrals to HiCap, Burlington-Edison School District Office,
927 E. Fairhaven Ave., Burlington, WA 98233.

HiCap Referrals are on-going and there is no deadline.  

The District Multidisciplinary Team will review referral forms.  If the student is deemed to be eligible for HiCap assessment, the Parent/Guardian will be contacted for consent and to arrange for testing during the next round of testing.  There are 2 testing periods in the school year; in Oct/Nov, & March.

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E-Mail-Adresse *
Student Name *
School *
Grade/Teacher *
Date of Birth
Parent/Guardian
Phone #
Name of person completing this form *
Date *
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