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Parent/Community Member Nomination Form

Parent/Community Member Nomination Form

Nomination/Questionnaire Form
Parent/Community Member

Your Name: ______________________________  Your Child's Name: _________________________________

Child's Age __________  Child's School: ______________________________ Today's Date: _______________

Please Indicate how often you have observed your child engaging in the characteristic behavior listed. In addition, in the comments section, please give examples of what you have seen from your child's experiences that support that particular characteristic. Please note, this form will not be processed without the comments section being completed for each "most of the time" rating.

Indicator Rarely Some of
the time
Often Most of
the Time

1. My child will spend more time and energy than his/her age-mates on a topic of his/her interest.


2. My child is a “self-starter” who works well alone, needing few directions and a little supervision.

3. My child sets high personal goals and expects to see results from his/her work.          
4. My child gets so involved with a project that (s)he gives up other pleasures in order to work on it.          
5. My child continues to work on a project even when faced with temporary defeats and slow results.          
6. While working on a project (and when it is finished) my child knows which parts are good and which parts need improvement.          
7. My child is a “do-er” who begins a project and shows finished products of his/her work.          
8. My child suggests imaginative ways of doing things, even if the suggestions are sometimes impractical.          
9. When my child tells about something that is very unusual, (s)he expresses themself by elaborate gestures, pictures, or words.          
10. My child uses common materials in ways not typically expected.          
11. My child avoids typical ways of doing things, choosing instead to find new ways to approach a problem or topic.          
12. My child likes to “play with ideas,” often making up situations which probably will not occur.          
13. My child often finds humor in situations or events that are not obviously funny to most children his/her age.          
14. My child prefers working or playing alone rather than doing something “Just to go along with the gang."          

Signature of Referring Person: _____________________________    Date: ______________________________