Pleasant Grove Elementary Gifted Online Referral Form

Thank you for your interest in referring your student for participation in gifted education services. This online form will begin the evaluation process. It is important to note that a referral does not guarantee that a student will be tested. Following the receipt of this referral, a gifted support teacher will collect data and present it to a Student Search Team. The team will make the decision as to whether or not testing is warranted. The Student Search Team will be in contact with you with more information.

1.	Student First Name:*

2.	Student Last Name:*

3.	Student Number:

4.	Current Classroom Teacher:*

5.	What hobbies does your student enjoy?*

6.	What interests does your student have?*

7.	What social activities does your student engage in?*

8.	Has your child received an individual award with superior ratings such as the Spelling Bee, Social Studies Fair, Science Fair, National History Day, Literacy Days,Duke Talent Search, Media Festival, or other? If so, what award did they receive, and what was their score?

9.	What subjects does your student enjoy studying? Do they study subjects outside of school and the regular curriculum? If so what are they?*

10.	Why do you feel that your student should be evaluated for gifted services?*

11.	Has your child received any prior gifted evaluation assessments? If so what were they, when were they administered, and who administered them?

12.	If your student is entering Henry County Schools from another school district or private school, please provide information on their most recent teacher.

The gifted evaluation process is as follows: 1) Referral form is received by the school's gifted support teacher. 2) The gifted support teacher collects data to provide to the Student Search Team. 3) The school-based Student Search Team will evaluate the referral form and data collected by the gifted support teacher to determine if testing is needed. 4) If testing is needed, assessments will be given in the areas of mental ability, achievement, motivation, and creativity. 5) Results of the assessments and all data collected will be reviewed for accuracy and proper procedures by an eligibility committee. 6) All results will be communicated in writing within 30 school days of the completion of the assessment process. 7) If the student is eligible for gifted education services, the school contact will provide information regarding the delivery of these services.

	I understand that the decision to test my student for gifted services is based on a review of data by a school-based Student Search Team. The data provided to the team will consist of data points on motivation, achievement, ability, and creativity. Referral to the school-based team does not guarantee eligibility for testing.

13.	I wish to refer my student for consideration to receive gifted services. Please type your complete name in the field below. *

14.	Phone Number (please enter with no dashes or parentheses):*

15.	Parent/Guardian Email Address:*