Series 610.1P - Application to Serve on the Gifted and Talented Advisory Council

Adopted: June 2006
Revised: October 2019

Name (please print) ___________________________________________________________
first last

Address ______________________________________________________________________

city zip code

Phone ( ) Email __________________________________________

Occupation ___________________________________________________________________

What is your connection to the school district? (Please check all that apply.)

1. Parent/guardian of an identified gifted and talented child(ren) 

Please specify each child’s school and grade:

School ___________________________________Grade _________

2. District employee:

elementary gifted and talent development teacher 

elementary classroom teacher 

elementary principal 

middle school gifted and talent development teacher/coordinator 

middle school classroom teacher 

middle school principal 

high school honors/advanced placement (AP) teacher 

high school administrator 

3. High school student: School ____________________ Grade ___________ 

What expertise can you bring to the Gifted and Talented Advisory Council?

______________________________________________________________

What is your experience and/or education related to gifted education? ______________

______________________________________________________________

______________________________________________________________

Why are you interested in serving on the Gifted and Talented Advisory Council? _____

______________________________________________________________

List two references:

1. Name _______________________________ (_______)_____________ (_______)_____________

daytime phone evening phone

Relationship _____________________________________________________________________

2. Name _______________________________ (_______)_____________ (_______)_____________

daytime phone evening phone

Relationship _____________________________________________________________________

signature date

THANK YOU FOR YOUR INTEREST! Please submit this completed application to:

Director of Teaching and Learning, Independent School District 196,
3455 153^rd Street West, Rosemount, MN 55068 or fax it to: 651-423-7614.

Procedures/610.1P/10-03-19

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