Application for Membership
Applicant Information
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Name Date
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Address
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City, State, Zip Code
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Telephone Cell Phone Email
School Information
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Date Enrolled Expected Graduation Cumulative GPA (weighted / unweighted)
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High School Honors Classes Taken
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Dual Credit or Advanced Placement Classes Taken ______________________________________________
Extra-curricular Activities
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Membership in Other Honor Societies
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Membership in Service Clubs
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Membership in Sports Teams
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English Classes
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Cumulative High School English GPA (weighted / unweighted)
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English Classes Taken (indicate level AND grade earned)
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English-related Classes Taken AND Grade Earned (i.e. Drama, Mass Communication, Speech, or Journalism)
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English-related Activities (i.e. articles or poems published in school and non-school publications, speeches given to the student body, or related activities.
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Miscellaneous
Have you ever been referred to a principal or assistant principal for serious misconduct or academic dishonesty? Yes ______ No ______ If yes, please explain. ________________________________
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Writing sample (optional): The applicant is invited to attach an optional piece of writing. It may be an essay, a short-story, poem, speech, song, dramatic scene, or some other genre. When appropriate, a video tape may be used. The purpose is to give the applicant an opportunity to illustrate skill and mastery in the English language.
Statement: To the best of my knowledge, the above information is true and correct. False or misleading information will result in cancelled membership.
Applicant Signature ___________________________________________________________________________
Applicant: Do not write in shaded area