Marysville School District 25

Highly Capable Student Referral Form for 2025-26 School Year

17 Questions

HIGHLY CAPABLE REFERRAL AND PERMISSION TO ASSESS
Due By: January 10, 2025

(THIS SIGNED REFERRAL FORM IS REQUIRED PRIOR TO ASSESSMENT)

1) Student's FULL Name Required*

2) Student's Date of Birth Required*

- Hover over and click the date - Click the current year - Scroll through the list of years and select the right year - Once you've selected the year, click the top arrows and scroll through until you find the right month - Once you're on the right month, click the date - See that the month, date, and year have changed successfully

3) Student's Home Address Required*

4) Student's Grade Level Required*

5) School Currently Attending Required*

6) Teacher's Name Required*

7) Referring Person FULL Name Required*

8) Referring Person Relationship to Student Required*

Parent/Guardian

School/District Staff

Other

9) Referring Person Phone Number Required*

Format: 123-456-7890

10) Referring Person Email Required*

11) Is this student attending their current school on a variance or district transfer? If yes, please add the name of the student's neighborhood school: (optional)

12) If the student's first language is a language other than English, please list the language(s) below. (optional)

13) Please check any program that applies to this student: (optional)

Multilingual Services

Special Education

504 Plan

14) List any additional factors that may affect the ability of this student to take the test: (optional)

15) Has this student been assessed for a gifted program before? If yes, when and where? (optional)

16) Is this student being assessed for another school/district this year? If yes, when and where? (optional)

17) Referral Consent/Acknowledgment or Parent/Guardian Permission for Assessment Required*

Referral Consent/Acknowledgment: By signing below, I acknowledge that I have referred a student for possible highly capable eligibility. Parent/Guardian Permission for Assessment: By signing below, I am providing my consent. I permit the Marysville School District to test my child to determine eligibility or possible placement in the Highly Capable program.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

Marysville School District 25
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Highly Capable Student Referral Form for 2025-26 School Year

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District4220 80TH STREET NEMarysville, WA 98270360-965-0000msd25@msd25.org

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