Gifted Student Contact List

1. Gifted Student Information

Dear Gifted Student and Parents,

Thank you for your interest in our Program(s). Please take a moment to answer all 10 of the questions on this contact form.

I look forward to working with you,
Dr. Demetrikopoulos

Melissa K. Demetrikopoulos, Ph.D.
Director of Scientific Communications
Chair, Division of Program Development and Assessment
Institute for Biomedical Philosophy
GiftedInfo@BioPhi.org

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* 1. For the following questions please provide the information requested.

Parent/Guardian:

Student names from eldest to youngest

Home phone

Address

City/Town/Zip

State

Parent Email Address

Student 1 Email Address

Student 2 Email Address:

Parent Cell Phone Number:

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* 2. How do you prefer to be contacted? Please mark all that apply.

	Best Way to Reach Me	Ok way to reach me	Not an efficient way to reach me	You will never find me this way
Home Phone	Home Phone Best Way to Reach Me	Home Phone Ok way to reach me	Home Phone Not an efficient way to reach me	Home Phone You will never find me this way
Parent Cell Phone	Parent Cell Phone Best Way to Reach Me	Parent Cell Phone Ok way to reach me	Parent Cell Phone Not an efficient way to reach me	Parent Cell Phone You will never find me this way
Parent Email	Parent Email Best Way to Reach Me	Parent Email Ok way to reach me	Parent Email Not an efficient way to reach me	Parent Email You will never find me this way
Student Email	Student Email Best Way to Reach Me	Student Email Ok way to reach me	Student Email Not an efficient way to reach me	Student Email You will never find me this way
Postal mail	Postal mail Best Way to Reach Me	Postal mail Ok way to reach me	Postal mail Not an efficient way to reach me	Postal mail You will never find me this way

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* 3. Please answer the following question with the Month Day and Year.

Date of Eldest Student's birth

Date

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* 4. Please answer the following question with the Month Day and Year.

Date of Youngest Student's birth

Date

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* 5. Gender

	Male	Female
Eldest Student	Eldest Student Male	Eldest Student Female
Student 2	Student 2 Male	Student 2 Female
Student 3	Student 3 Male	Student 3 Female
Student 4	Student 4 Male	Student 4 Female
Student 5	Student 5 Male	Student 5 Female
Student 6	Student 6 Male	Student 6 Female
Student 7	Student 7 Male	Student 7 Female

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* 6. Please indicate type of gifted program that your child participates in during the school year (mark as many as apply).

Grade Skipping

Course Acceleration (ie 3rd grader in with 4th graders for one or more subjects)

Full-time gifted program

Pull out part-time gifted program

Other (please specify)

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* 7. Current Grade Level

	K	1	2	3	4	5	6	7	8	9	10	11	12
Eldest student	Eldest student K	Eldest student 1	Eldest student 2	Eldest student 3	Eldest student 4	Eldest student 5	Eldest student 6	Eldest student 7	Eldest student 8	Eldest student 9	Eldest student 10	Eldest student 11	Eldest student 12
Student 2	Student 2 K	Student 2 1	Student 2 2	Student 2 3	Student 2 4	Student 2 5	Student 2 6	Student 2 7	Student 2 8	Student 2 9	Student 2 10	Student 2 11	Student 2 12
Student 3	Student 3 K	Student 3 1	Student 3 2	Student 3 3	Student 3 4	Student 3 5	Student 3 6	Student 3 7	Student 3 8	Student 3 9	Student 3 10	Student 3 11	Student 3 12
Student 4	Student 4 K	Student 4 1	Student 4 2	Student 4 3	Student 4 4	Student 4 5	Student 4 6	Student 4 7	Student 4 8	Student 4 9	Student 4 10	Student 4 11	Student 4 12
Student 5	Student 5 K	Student 5 1	Student 5 2	Student 5 3	Student 5 4	Student 5 5	Student 5 6	Student 5 7	Student 5 8	Student 5 9	Student 5 10	Student 5 11	Student 5 12
Student 6	Student 6 K	Student 6 1	Student 6 2	Student 6 3	Student 6 4	Student 6 5	Student 6 6	Student 6 7	Student 6 8	Student 6 9	Student 6 10	Student 6 11	Student 6 12
Student 7	Student 7 K	Student 7 1	Student 7 2	Student 7 3	Student 7 4	Student 7 5	Student 7 6	Student 7 7	Student 7 8	Student 7 9	Student 7 10	Student 7 11	Student 7 12

Please note any classes taken out of their current grade level

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* 8. How did you hear about the program?

Friend

Teacher

Gifted Association

School Gifted Program

Other Gifted Program

Flyer

Other (please specify)

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* 9. Is there any other important information that we should know?

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* 10. Refer a Friend: If you know other students who may be interested in this program, please provide their contact information so that we can send them program information.