NORWALK PUBLIC SCHOOLS, NORWALK, CT

Middle School Academically Talented Program

Student Self Nomination Form

Student Name __________________________________________   Date ______________________

Address ____________________________________________         Grade _____________________

 ________________________________________________    School __________________________

ZIP

Telephone Number (     ) ______________________________  Birth Date ______________________

1. In what areas do you have special talent or ability?

2. In which subjects or courses do you do superior work?

3. What are the areas, topics, or activities in which you have special or strong interests?

4. Describe a project, product, or performance that you have done or created in which you excelled.        

5. How many hours per week do you spend in voluntary reading?  __________________ Hours

6. What are your areas of special interest in reading?

7. Why do you want to be in this special program?

Students in the Academically Talented Program are expected to strive for excellence in all their work and to work harder than they normally do in regular classes.  If you agree with this expectation, sign your name below.

Student Signature