Gifted Testing Consent
COMPLETE ALL AREAS OF THIS FORM. IN ORDER FOR YOUR CHILD TO TEST, WE MUST HAVE THIS FORM AT THE TIME OF TESTING.
PLEASE PRINT LEGIBLY.
STUDENT ID # ______CURRENT SCHOOL ______
(if RPS Student) (if summer, last school)
CIRCLE CURRENT GRADE (if summer, last grade): KDG. 1 2 3 4 5 6 7 8
DATE OF BIRTH: MO._____ DAY _____ YR _____ MALE ______FEMALE ______
PLEASE USE LEGAL NAME OF CHILD:
______
LAST NAME FIRST NAME MIDDLE INITIAL
* ETHNICITY: (Choose only one) Is this student Hispanic/Latino? o No o Yes
* RACE: (Choose one or more)
Mail to: Renaissance Gifted Program, Washington School, 1421 West Street, Rockford, IL 61102 OR Fax: 815-966-3347
o 1- BLACK or AFRICAN AMERICAN
o 2- WHITE
o 3- AMERICAN INDIAN or ALASKA NATIVE
o 4- ASIAN
o 7- NATIVE HAWAIIAN or OTHER PACIFIC
ISLANDER
Mail to: Renaissance Gifted Program, Washington School, 1421 West Street, Rockford, IL 61102 OR Fax: 815-966-3347
LANGUAGE SPOKEN IN THE HOME: ______
PARENT RELATION: Choose only one
Mail to: Renaissance Gifted Program, Washington School, 1421 West Street, Rockford, IL 61102 OR Fax: 815-966-3347
o 1-BOTH PARENTS
o 21-SINGLE PARENT/MOM
o 22-SINGLE PARENT/DAD
o 23-JOINT CUSTODY
o 24-MOM & STEPDAD
o 25-DAD & STEPMOM
o 31-OTHER/FOSTER HOME
o 32-OTHER/RELATIVE
o 33-OTHER/FACILITY
Mail to: Renaissance Gifted Program, Washington School, 1421 West Street, Rockford, IL 61102 OR Fax: 815-966-3347
I give consent for my child to be tested for the RPS Centralized Gifted Program. I understand that the scores from this testing may be shared with public school personnel and that gifted program staff might obtain data regarding my child's achievement levels and approach to academic tasks from his/her school.
H -
______C - ______
PRINT PARENT/GUARDIAN NAME PARENT/GUARDIAN SIGNATURE PHONE(S)
______, IL ______
ADDRESS BOX/APT# CITY ZIP
EMAIL (Please Print Legibly) ______
If there is a parent/guardian in a different household:
H -
______C - ______
PRINT PARENT/GUARDIAN NAME PARENT/GUARDIAN SIGNATURE PHONE(S)
______, IL ______
ADDRESS BOX/APT# CITY ZIP
Mail to: Renaissance Gifted Program, Washington School, 1421 West Street, Rockford, IL 61102 OR Fax: 815-966-3347