NORTHVILLE PUBLIC SCHOOLS
Summer Testing for the 2012 – 2013 School Year
Parent Request Form for Students Who Have Enrolled After June 1, 2012
Alternative Learning Program for Students (ALPS)
Please Print or Type
Student Gender Birth Date
Grade in Fall of 2012
Mother’s Name Contact Number
Father’s Name Contact Number
(You will receive a confirmation email only if you email this form to: AdvProgram@northville.k12.mi.us. Do not mail.)
You will need to first register at the school the student will be attending and then complete this form
and submit it by June 12, 2012.
Testing Place: Hillside Middle School, Computer Lab 130
Testing Date and Time: The NWEA tests are about an hour in length although they are untimed.
Check one reading and one math preference:
June 18 June 19
9:00 a.m. (Reading) 9:00 a.m. (Math)
11:00 a.m. (Math) 11:00 a.m. (Reading)
1:00 p.m. (Math) 1:00 p.m. (Reading)
In addition to the testing, your input can provide additional information that may be helpful in the
screening process. Please complete the questions below, then sign and submit the form.
Has child been tested by a psychologist? No Yes Date
Tests (include copy if test is to be considered)
Prior participation in a gifted & talented program? No Yes Location
(Please provide some type of documentation confirming successful completion of the program.)
If your child was born in another country, what is the
year of your child’s date of entry into the U.S.?
What year was the child first enrolled in a U.S. school?
What is your child’s native language?
What language(s) is/are spoken at home?
NORTHVILLE PUBLIC SCHOOLS
Please read the statements carefully and indicate the number which best indicates the degree to
which the behavior or characteristic is observed in the child.
1. Indicates characteristic is SELDOM OR NEVER observed.
2. Indicates characteristic is OCCASIONALLY observed about half the time.
3. Indicates characteristic is observed to a CONSIDERABLE DEGREE or often.
4. Indicates the characteristic is observed ALMOST ALL OF THE TIME.
LEARNING CHARACTERISTICS Never Always
1. Is very curious about a variety of things. 1 2 3 4
2. Will attend to an activity for a long period of time. 1 2 3 4
3. Learns academic materials with little instruction. 1 2 3 4
4. Answers questions in detail with a lot of information. 1 2 3 4
5. Knows about many things that other children 1 2 3 4
his/her age are unaware of.
6. Becomes absorbed and truly involved in certain topics of 1 2 3 4
7. Strives for perfection (establishes high personal 1 2 3 4
8. Is self-critical. 1 2 3 4
9. Concerned with right and wrong, good and bad. 1 2 3 4
10. Questions authority. 1 2 3 4
11. Imaginative: tries to do things in different, unique ways. 1 2 3 4
12. Recognizes that there are various alternative ideas or 1 2 3 4
solutions to problems and questions and generates many
13. Often does things in own way. 1 2 3 4
14. Is uninhibited in expressions of opinion; sometimes 1 2 3 4
radical and spirited in disagreement; hangs onto own
15. Has a keen and varied sense of humor (appreciates 1 2 3 4
Signed by Parent/Guardian ________________________________ Date
Your signature below provides permission to begin collecting data, including testing, on the
named child. Letters will be mailed in mid-August notifying parents of placement decisions.
Please email this form to: AdvProgram@northville.k12.mi.us or
(ONLY those parents who submit the form via email will receive a confirmation email
indicating the form has been successfully submitted.)