Student’s name: _________________________________________ Date: _________

School: __________________ Teacher: ______________________ Grade _________

D.O.B. __________________

Name of person referring: _______________________________________________

Relationship to student: _________________________________________________

Address: ____________________________________________________________

_____________________________________________________________

Phone numbers: Home ______________________ Work: _____________________

1. What do you feel are this student ’s most significant talents or skills?

2. Describe briefly the context in which you have witnessed this student's abilities.

3. Describe briefly your involvement with this student.

4. Do you feel this student has any significant difficulties or needs relating to her/his area of talent?

5. Why do you think this student would benefit from participation in the EXCEL program?