Student’s name: _________________________________________ Date: _________

School: __________________ Teacher: ______________________ Grade _________

D.O.B. __________________

Parent Name(s): _______________________________________________

Address: ____________________________________________________________

_____________________________________________________________

Phone numbers: Home ______________________ Work: _____________________

1. What do you feel are your child’s most significant talents or skills?

2. What problems or weaknesses does your child have, academically or socially?

3. What activities occupy your child’s time after school and on weekends? (Hobbies, collections, special lessons, etc.)

4. Do you feel your child’s educational needs are being met in the regular classroom? Please be a specific as possible.

5. What early evidence was there of your child’s superior ability?

6. Why do you think your child would benefit from participation in the EXCEL program?