Madison-Champaign
Educational Service Center
Providing outstanding customer-based service
Dr. Daniel Kaffenbarger, Superintendent
Matthew Ketcham, Treasurer
Referral Form
Child _____________________________ School ___________________________ Grade ____________
Is referred for possible identification as gifted in the following area(s):
☐ Superior Cognitive Ability
☐Specific Academic Ability
☐ Mathematics
☐ Science
☐ Reading
☐ Writing
☐ Social Studies
☐ Creative Thinking Ability
☐ Visual or Performing Arts Ability
(such as drawing, painting, sculpting,
music, dance, drama)
Reason
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Signature of Person Initiating Referral
Person or Relationship to Child
Phone
Date
_______________________________________ _______________
Signature of Person Receiving Referral
Date
NOTE: A parent may request assessment through any verbal or written means to the building administrator.
PLEASE RETURN TO BUILDING ADMINISTRATOR, GIFTED INTEVENTION SPECIALIST (IF APPLICABLE) OR
MICHELE ROBERTS, MADISON-CHAMPAIGN ESC AT THE ADDRESS BELOW
1512 S. US Hwy. 68, Suite J100, Urbana, Ohio 43078
Phone: (937) 484-1557 ♦ Fax: (937) 484-1571 ♦ www.mccesc.k12.oh.us