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B u r naby Bo a rd o f Ed u c a t i o n S D 4 1

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Input Form Name

Name

School-Based Input Form Email

Email
Legal Student Name
Submit
Wesley Jacob Cheung

Current Grade

5
Programs
Age

10 MACC Program
BETA Mini School (Alpha
Gender
Secondary)
Male AP Capstone

Date of Birth (YY/MM/DD)

11/01/26

Student Number Resources

2086102
Questioning
School * Depth and Complexity
iPad Apps
Forest Grove Elementary School
At the DLRC
Classroom Teacher

Derrick Li

Classroom Teacher Email *

derrick.li@burnabyschools.ca
Enter Email

derrick.li@burnabyschools.ca
Confirm Email

Parent Name *

Phoebe Cheung

Parent Contact Information

604-831-0573

This form should be completed by the

current classroom teacher
(recommended consultation with
School Based Team and previous
classroom teacher). The information
provided in this form is a significant
part of the student's application and
will be kept confidential.
Please list all SBT participants included in the
development of this input form and indicate their
position.

Derrick Li

Grade 5/6 Homeroom Teacher

Forest Grove Elementary School

Please list any current/previous Ministry

designation(s), if applicable.

Not applicable

If applicable, please provide a copy of the student's IEP/SLP in

the application package, along with any additional evidence to
support application.

Does this student require support from an

educational assistant? If yes, please indicate how
much support is required (e.g., full-time, part-time).

No

Has this student been accelerated one full grade or

more? If, yes please provide further information
below.

No

Student Traits
Students who flourish in a Mini School environment tend to
demonstrate the following characteristic traits or display
the potential to develop them. Please scroll down in each
box and choose the appropriate number that relates to the
student when they are engaged in a creative or complex
task.

Demonstrates high task commitment

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is socially responsible (resolves conflicts with

others peacefully)

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is collaborative with other learners

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Has the ability to deal with complexity

 1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is a divergent thinker

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Appreciates and engages in open-ended tasks

1- very rarely
2- rarely
3- sometimes
4- frequent
5- very frequent

Has a willingness to take risks

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Shows evidence of a passion for learning

 1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Shows a desire to become an independent learner;

takes responsibility for own learning

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Demonstrates high intellectual ability

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Shows a willingness to reflect on own learning

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Demonstrates ability to be a flexible learner

 1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is a creative thinker: fluency, flexibility and

originality of thought

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Demonstrates strong problem-solving skills

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is a critical thinker

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Is able to manage stress

 1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Perseveres even when early efforts are not

successful

1- very rarely
2- rarely
3- sometimes
4- frequently
5- very frequently

Please describe any social-emotional concerns?

(e.g., anxiety, withdrawal, social skills)

Wesley does not have any social-emotional

concerns.

Please describe any behavioural concerns? (e.g.,

aggression, defiance, attention, hyperactivity)

Wesley is a very social student. He enjoys and

benefits from socializing with his peers during
his school days. So far, I have not seen Wesley
has any behavioural concerns such as
aggression, defiance, attention, or hyperactivity.

Academic Performance
Please describe the student's performance in the following
academic areas (e.g., grade-level, adaptations, enrichment,
support required).
Please describe the student's reading abilities.

Wesley enjoys reading novels and short stories.

Wesley is able to effectively communicate the
main idea of a story and summarize with rich
details. He is also able to respond to literature
in number of ways: using graphic organizers,

Please describe the student's writing abilities.

Wesley utilizes a variety of resources as he

writes organized and creative stories. He is also
able to self-edit using teacher-generated self-
edit checklists. He drafts ideas fluently, then
revises and proofreads to produce a final copy
Please describe the student's mathematical
abilities.

Wesley is highly proficient in math. I am

challenging him. It is apparent that Wesley enjoys
math. He always participates in class and can
always explain his work.

Additional Information

Please describe how suitable you believe this

program would be for the student. In your opinion,
what would work well or not well for the student?

I believe this program is very suitable for Wesley.

Please provide any further information you feel is

important.
Submit

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