5151 Form 1

NEW HARTFORD PUBLIC SCHOOLS

REFERRAL TO DETERMINE ELIGIBLITY FOR GIFTED AND TALENTED

Student: _______________________ DOB: _________ Age: __________  Grade: __________

Parent/Guardian: ______________________ Primary Language  English  Other

Address:   _________________________________   Referred By: ___________________

                 _________________________________   Referral date: __________________

Telephone:  ______________________        Relationship to Child: _______________________

1.  AREA(S) IN WHICH CHILD EXCELS:

Check major area(s) of outstanding performance, and briefly describe the child s performance in each area checked. If you have identified more than one area, circle the area you consider to be the highest priority.

[  ]   Academic          [  ]   Musical       [  ]   Artistic (visual arts)       [  ]   Other (specify) _________________________________

A.  Describe Superior Performance Area: (attach supporting documents)

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B.  Describe Child s Ability to Self-Initiate:

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2.  Referral History:

Has this child been considered for the Gifted and Talented program in the past?

[  ]   Yes     [  ]   No

If yes, attach previous referral information.

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3.  Other Relevant Information

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4.  Parent Notification

Has the parent/guardian been notified regarding the child s abilities?

[  ]   Yes   [  ]   No

If yes, method of notification: _______________________________________________

Date(s) parent/guardian was notified: _________________________________________

Signed: ___________________________________  Date: ________________________

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(Signature of individual completing this form)