Gifted Outreach Programs

Application Forms
2017 - 2018

2017-2018 VSB Gifted & Enrichment Education 1

 Elementary Gifted/Enrichment Program Application 1
Referral Form for 2017 2018 Candidates

School: _________________________________________________________________________________
Student Surname: __________________________________ First Name: _____________________________
DOB: ____________________ Current Grade __________ Gender: ________________________________
Designations (list all): ______________________________________________________________________
Principal: _______________________________________ Email: _________________________@vsb.bc.ca
Gifted Ed Contact Teacher: _________________________ Email: _________________________@vsb.bc.ca
Form completed by: _______________________________Title: ____________________________________

Does the student have a Pyscho-Educational Assessment: Yes No Date ______________

Has the student written the Insight Test? Yes No
If Yes, Gc___ Gv___ Gf___ Date Tested _________________
Previous Gifted Outreach Program(s) attended in last 2 years: _______________________________________
Has this child ever been assigned a SSA/Behaviour Consultant/or have a behavior plan? Y N
Areas of exceptional talent: __________________________________________________________________

Check () Areas requiring Support

ELL Social/emotional
Organization Self-Regulation
Written Output Medical/Specify
Reading Other

Are there significant conditions or stresses that might influence school performance? (e.g., medical
conditions, learning disabilities, behavioural concerns, difficulties working in groups, attention issues).
_______________________________________________________________________________________
_______________________________________________________________________________________

Application Deadline: June 14th, 2017

Please send via blue bag to:

Gifted Mentor, Learning Services Garibaldi

Retain Original Forms in Students Permanent File

2017-2018 VSB Gifted & Enrichment Education 2

 Elementary Gifted/Enrichment Program Application 2
School Based Team - Needs Assessment for Gifted Learners
To Be Completed by School Based Team and Submitted with Referral Form

Student Name: Current School: Gr: Date: _______

Use the following scale to indicate how frequently you observe the traits listed below. Please use check mark. ()

Gifted Learner Characteristics Never Sometimes Often Always

1 Extensive vocabulary
2 Advanced discussion verbal skills
3 Takes risks, experiments, readily
4 Keen observer
5 Thrives on complexity
6 Grasps abstract concepts
7 Goes beyond what is taught or required
8 Prefers new, original ways of doing things
9 Is able to work well in a team
10 Has fluency of ideas, sees many possibilities
11 Reads well and widely
12 Excels in logical/mathematical reasoning
13 Extremely curious, questioning
14 Demonstrates problem-solving skills and strategies
15 Strong visual/spatial skills (hands-on work.)
16 Demonstrates a sense of humour
17 Has interest in challenging self
18 Has a high level of task commitment.
19 Works effectively by his/herself

Why are you referring this student to this program?

_________________________________________________________________
How has the student shown s/he is passionate about his/her exceptional interest?
_________________________________________________________________
How do you see a mentor being involved with the student? (Required for Mentorship program only)
_________________________________________________________________
Areas of exceptional talent/interest.
_________________________________________________________________

2017-2018 VSB Gifted & Enrichment Education 3

 Elementary Gifted/Enrichment Program Application 3
2017-2018
Student Name: School: Current Gr.________

Select up to three programs and rank in order of preference 1, 2, 3. Read program descriptions to
ensure student meets program criteria.

Challenge Centers at Brock Elementary

Priority # Program Gr. Priority # Program Gr.
CC1 Narrative Writing 6/7 CC11 Deliberate Debators 6/7
CC2 Digital Storytelling 3/4 CC12 Creative Problem Solving 3/4
CC3 Learn to Code 6/7 CC13 Exploring the Universe 1/2
CC4 Awesome Authors 2/3 CC14 Global Citizenship 5/6
CC5 Math Challenge 6/7 CC15 Mathematics in the Real World 4/5
CC6 Chemistry 4/5 CC16 Physics for Kids 4/5
CC7 CSI Forensics 4/5 CC17 Poetic Picassos 4/5
CC8 Poetry 1/2 CC18 Introduction to Coding 2/3
CC9 Stop Motion 3/4 CC19 Future is Wild 4/5
CC10 Innovation Inventions 2/3

Mentorship / Explorations at Mackenzie Elementary

Priority # Program Gr. Priority # Program Gr.
M Long Term Mentorship 4-7 PM4 Personal Interest Project 7
PM1 Pre-Mentorship 3 PM5 What's It All About 6/7
PM2 Pre-mentorship 4 EM1 E-Mentorship 5/6
PM3 Pre-mentorship 5/6 EM1 E-Mentorship 6/7

Seminars at Tecumseh Elementary (unless otherwise noted)

Priority # Program Gr. Priority # Program Gr.
S1 S.T.E.A.M. - Maker Space 4/5 S8 Engineering 4/5
S2 S.T.E.A.M. - Maker Space 6/7 S9 Engineering 5/6/7

S3 Architecture - Designing Our World 5/6/7 S10 Kinetic Sculpture 5/6/7

S4 Playwriting and Acting 6/7 S11 Young Writers 4/5
S5 Exploravision 4/5/6 S12 Spoken Word 5/6/7
S6 Young Writers 6/7 S13 Young Environmentalists 4/5/6
S7 Engineering for Girls 4/5

Please send referrals via blue bag to: Gifted Mentor, Learning Services Garibaldi

2017-2018 VSB Gifted & Enrichment Education 4

 Mentorship Program @ Mackenzie
2017-2018
If you would like to find out if any of the students in your school might be a good
candidate for a mentorship, ask them to complete this survey.

Name _________________________________________________________________________________

In my spare time I love to _________________________________________________________________

Ive been interested in this for ______________________________________________________________

I am curious about _______________________________________________________________________

If I could learn about anything at school it would be ____________________________________________

______________________________________________________________________________________

I know lots more about _________________________________________________than most kids my age.

My hero/role model is ____________________________because _________________________________

______________________________________________________________________________________

I would like or would not like to have a person who has more knowledge and experience help me
with:

This survey is to help you identify students in your school who might be a good candidate for a mentorship. Ask the
students to complete this survey. If you see strong areas of interest and passions the student may be a good
candidate. The topic needs to be one in which the student needs a mentor and one that is not readily available in the
community.

For example, do not refer a student who is passionate about playing video games but do refer if a student is designing
and coding video games. Do not refer if the student is passionate about playing hockey but do refer if s/he is
interested in the stats or history of the game.

2017-2018 VSB Gifted & Enrichment Education 5

 Gifted Education - School Request Form
For Placements

School Program Requested Office Use Only - Final

Current Challenge
Last Name First Name All Designations
Grade
Gender
Centre
Mentorship Seminar

1
2
3
4
5
6
7
8
9
10

Students must be prioritized.

(Please initial)
Gifted Contact: ________________________________ Administrator:__________________________________

Challenge Centre Experience: Pull-in programs for students interested in Challenge Centre
Mentorship/Exploration: Supported individual study in area of demonstrated passion
Seminar Program: On-going cohort experience for students requiring significant enrichment

Return this sheet to: Gifted Mentor, Learning Services Garibaldi

Deadline: June 14th, 2017

Please keep a school copy for your records

2017-2018 VSB Gifted & Enrichment Education 6