CISD GT Referral - Project Education

Student ID is required to submit this form, please have it ready before submitting it. If you do not know your student's ID, please contact their campus to obtain it before proceeding. Dear Parent, As your child's first teacher, you are a valuable source of information about your child's habits and the ways he or she learns new things. To help us in providing for your child's educational needs, please complete and return this questionnaire as soon as possible. Thank you for your prompt attention.

General Information

Student ID (numbers only)

Student First Name

Student Last Name

Student Campus

Grade

Date of Birth: (MM/DD/YYYY)

Homeroom Teacher (K-5) Last Name Only (If known)

Your relation to the student

Name of person submitting this form:

Phone number of person submitting this form:

Email of person submitting this form:

Parent/Guardian Permission For Assessment And Participation

My typed name below represents my signature and confirms my permission for Cleveland ISD to assess my child for advanced learning opportunities such as gifted services or acceleration and for my child to participate in any such services for which he or she is identified,

Parent/Guardian Signature:

Date:

Previous GT Screening

Has the student previously qualified for a gifted program?

If student previously qualified in a gifted program, please give as much of the following information as you know.

Name of gifted program:

School District:

Contact Person:

Phone:

Address including City, State and Zip:

Parent Inventory

Instructions: Please rate by number each item that you feel best describes your child. 0= Does not describe my child 1= Often applies to my child.

Is very aware of physical surroundings.

Asks questions about abstract ideas like love, feelings, relationships, or justice.

Needs less sleep than other children of the same age.

Moves around a lot. Is very active-sometimes seems hyperactive.

Talked early.

Has a long attention span for things that interest her/him.

Is extremely concerned or curious about the meaning of life and death.

Reacts intensely to noise, light, taste, smells, or touch.

Craves stimulation and activity. Is rarely content to sit idle.

Is very emotional-cries, angers, or excites easily.

Has an excellent memory.

Insists that people " be fair." Complains when things are "unfair".

Is extremely curious-constantly asks "Why?" "How?" "What if?"

Becomes so involved that he or she is not aware of anything else. "Lost in own world."

Explains ideas in complex, unusual ways.

Is very interested in cause-effect relationships.

Reasons well. Thinks of creative ways to solve problems.

Is very interested in clocks, calendars, maps, structures.

Has vivid imagination and improvises games or toys from commonplace material.

Is extremely creative-uses materials in unusual ways; makes up elaborate stories, or excuses. Sees many possible answers/solutions. Spends free time drawing, painting, writing sculpting, or singing.

Has spontaneous and/or advanced sense of humor.

Likes to play with words. Uses advanced sentence structure and vocabulary.

Is often singing, moving rhythmically; may tell stories or communicate by singing.

Memorizes songs.

Often prefers playing with older children or being with adults.

Creates complicated play and games.

Gives complex answers to questions.

Becomes extremely frustrated when body can't do what mind wants it to.

Has strong sense of self-control. Wants to know reasons for rules.

Is eager to try new things.

Can concentrate on 2 or 3 activities at one time.

Organizes and leads activities.

Has a drive to be "perfect.”

Takes objects apart.

Wants to do things without help.

Does your student receive testing accommodations according to an IEP or 504 plan? This information is NOT used for identification purposes. It is ONLY used to determine if a particular testing environment is needed.

Describe any other strengths that usually apply to your child: