National Honor Society
Student Activity Information Form

Directions: Please complete all sections and submit to Brian Dickerson by (published deadline.) All information will be used by the Faculty Council to assist with the fair consideration of your candidacy during the selection process.

You may use this form as scratch paper. The final submission must be typed. A copy of this form is available on CD in the library or on the high school web site. To obtain a copy from the library please bring a disk.

Name______Year in School _____ GPA ______

I. Leadership Positions

List all leadership positions held in school, community, or work activities. Only include those positions in which you were directly responsible for directing or motivating others. For example, elected student body, class, or club officer; committee chairperson; team captain; newspaper editor; work area manager; or community leader. Position of leadership or responsibility (activities you were in charge of.)

Leadership Position / 9 / 10 / 11 / 12 / Your accomplishments as a leader / Printed name, signature and phone # of adult supervisor

List non-elected or informal leadership roles and activities at school and in the community where you’ve demonstrated leadership.

Activity you participated in / 9 / 10 / 11 / 12 / Demonstration of Leadership / Printed name, signature and phone # of adult supervisor

II.  School related activities:

List all activities in which you have participated during high school, include clubs, teams, musical groups, etc., and major accomplishments in each.

Activity / 9 / 10 / 11 / 12 / State how you have served others. / Printed name, signature and phone # of adult supervisor

III.  Community Activities

List community activities in which you have participated and note any major accomplishment in each. These should be any activities outside of school in which you participated for the betterment of your community. For example: church groups, clubs sponsored outside the school, boy or girl scouts, volunteer groups, or community art endeavors.

Community Activity / 9 / 10 / 11 / 12 / State how you have served others / Printed name, signature and phone # of adult supervisor

IV.  Work experience:

List any positions held in the summer or throughout the year. Work experience may be paid or volunteer. (Note: Although work experience is not a specific criterion for membership, many aspects of work experience may support the leadership, service and character criteria.)

Work experience / 9 / 10 / 11 / 12 / Accomplishments / Printed name, signature and phone # of adult supervisor

V.  Recognition and Awards:

List any honors or recognitions that you have received which support your candidacy for membership in the National Honor Society.

Recognition or Awards / 9 / 10 / 11 / 12 / State how this shows character or scholarship / Printed name, signature and phone # of adult supervisor

VI.  Character references:

A person of good character shows courtesy, concern, and respect for others and demonstrates the highest standards of honesty and reliability. Have two people other than an immediate family member provide a character reference to support your candidacy.

Typed Name of Reference / Describe their relationship to you. / Signature and Phone # for Reference

NOTE:

If you have excessive tardiness or absences within the school year please explain.

If you have had any referrals within the last school year please explain.

Write a paragraph describing why you want to join National Honor Society (please attach to this form).

I understand that completing this form does not guarantee selection to the Honor Society. I attest that the information presented here is complete and accurate. If selected, I agree to abide by the standards and guidelines of the chapter and to fulfill all of my membership obligations to the best of my ability.

Student Signature: ______Date: ______

I have read the information provided by my son/daughter on this form and can verify that it is true, accurate, and complete.

Parent Signature: ______Date: ______