Student Name: _________________________________________________________________

Class of: ______________________________________________________________________

Gifted Area: ___________________________________________________________________

Case Manager Name: __________________________  Date of Interview:  _________________

1. What courses are you currently taking in the area(s) for which you have been identified as gifted?  What grade do you expect to receive in this course at the end of the semester?

A.

B.

C.

D.
 

2. Are you seeking any curriculum modification in this (these) cours(s) at this time?

If you are seeking a curriculum modification in a course, please describe briefly,
to the best of you ability what kinds of additional challenges would make the
course a more enriching  learning experience for you.

 
A.  Course #1: _______________________: _____yes  _____no

      Suggested Modifications:
 
 
 

       B.  Course #2: _______________________: _____yes  _____no

       Suggested Modifications:
 
 
 

       C.  Course #1: _______________________: _____yes  _____no

       Suggested Modifications:
 
 
 

       D.  Course #1: _______________________: _____yes  _____no

       Suggested Modifications:
 
 
 
 

3. Have you recently received curriculum modification in any classes for which you have been identified as gifted?
 

_____yes    _____no
 

If you answered “yes” to the above question, please state the name of the course(s) in which the curriculum was modified to meet your needs.  Also, describe briefly the kind(s) of modification received.
 
 
 
 
 

4. List any Mentoring Experiences you might be interested in now or in the future.
    Please be as specific as possible regarding what kind of mentoring experience you
    seek.  Also, please specify the time of year (fall semester; spring semester; summer)
    that if would be most convenient for you to complete a mentorship.
 

A. Mentoring Interest #1: ___________________________________________________

B. Mentoring Interest #2: ___________________________________________________

C. Mentoring Interest #3:  ___________________________________________________
 

It would be most convenient for me to complete a mentorship in:

_____fall    _____spring    _____summer
 

5. Have you completed a mentoring opportunity as part of the Hononegah Gifted
    Program within the last year?  _____yes     _____no

If you answered “yes” to the above question, please describe briefly the kind(s) of
mentoring opportunity you completed.
 
 
 
 

6. List any Independent Study interests that you may want to pursue now or in the future.  Please be as specific as possible regarding what kind of Independent Study experience you wish to pursue.  Also, please specify the time of year (fall semester; spring semester; summer) that would be most convenient for you to complete an independent study.
 

A.  Independent Study Interest #1: ____________________________________________

B. Independent Study Interest #2: ____________________________________________

C. Independent Study Interest #3:  ____________________________________________
 

It would be most convenient for me to complete an Independent Study in:

_____fall    _____spring    _____summer
 

7. Have you completed an Independent Study within the Hononegah Gifted Program
    within the last year?  _____yes     _____no

If you answered “yes” to the above question, please describe briefly what your Independent Study entailed.  Also, please include the name of the faculty member who helped you complete your independent study.
 
 
 
 
 

        8.  Are you interested in a summer study program?  _____yes  _____no

If you answered “yes” to the above question, please describe briefly the kind of
summer study program(s) you are interested in pursuing.

a. Summer Study Interest #1:  _________________________________________

b. Summer Study Interest #2:  _________________________________________

c. Summer Study Interest #3:  _________________________________________
 

9.  Did you complete a summer study program last summer?  _____yes      _____no
 

If you answered “yes” to the above question, please describe briefly the kind of summer study program that was completed.  Please include the name of the institution that sponsored the program as well as a brief statement of what value the program had for you.
 
 
 

10. Are there any other special concerns or issues you would like to address with members of the Gifted Program?

_____yes   _____no
 

If you answered yes to the above question, please list your concerns here:
 
 

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