PARENT REFERRAL FORM

Office of High Ability Education  Administration Center  315 E. North Drive  Bloomington IN 47401

ELEMENTARY

High Ability Program

Please check the Elementary Application Checklist and Timeline for deadline to submit Parent Referral and all relevant materials.

Instructions: Please type or print legibly as you respond to the following questions. Downloadable version of form available at:

Student:______Age: Date of Birth:

(Last)(First)

CurrentSchool:______Grade:______Teacher:______

Parent/Guardian Name:______

Address: ______

(Street Address)(City)(State)(Zip)

Parent/Guardian’s e-mail address: Parent/Guardian’s phone #:

  1. What are some behaviors you have observed in your child which lead you to believe that he/she should be in a special

program for academically and intellectually high ability students?

2. What problems, if any, has your child experienced in school as a result of his/her abilities?

3. What are your child’s favorite activities at school?

4. What are her/his least favorite school activities?

5. What are your child’s major interests, hobbies, and free-time activities?

6. Describe briefly your child’s reading habits at home:

7. List some of your child’s most enjoyable reading materials:

8. List any awards or honors your child may have received:

9. Other information or comments:

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PARENT REFERRAL FORM

High Ability Behavior Characteristics

Please mark the high ability behavior characteristics that you have observed in your child. Examples of specific high ability behavior characteristics should be provided under the characteristic when applicable.

AbilityCreativityTask Commitment

Uses advanced vocabularyAsks questions, is very curiousSets own goals, standards,

and plans

Has a good memoryHas many ideasBecomes deeply involved in

some tasks

Learns very quicklySees thing in many different waysShows enthusiasm for

interests/activities

Seems to know many thingsOffers unique or unusual solutionsNeeds little external motivation

to questions or problems when pursuing preferred tasks

Generalizes skillfullyAdds interesting detailsPrefers to concentrate on

preferred tasks

Understands both concreteTransforms or combines ideasSeems to have a high level of

and abstract ideasenergy

Can state similarities and Sees implications or consequencesDoes not give up easily

differences in relationshipseasily

Understands cause and effectIs a risk-takerCompletes projects

Makes decisions comfortablyIs comfortable with disagreementsEagerly attempts new challenges

Enjoys learning new ideasFinds subtle humor, paradox, orAssumes responsibility

discrepancies in events or stories

Adapted from the Renzulli screening form.

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