MIDDLETOWNHIGH SCHOOLNORTH NationalHonor Society

Martha Pennington Chapter

Student Activity Information Form

Directions: Pleasecompleteallsections.Donotbemodest.Everybitofinformationcanbe usedbytheFacultyCounciltoassistwiththeselectionprocess.Completionofthisformdoes notguaranteeselection.Signaturesforeach activitymustbeobtainedtoverifyyour participation. Be sure to delete the examples prior to submission!!!

I.SchoolSponsoredActivities:Listallactivitiesinwhichyouparticipatedduringhigh school.

Activity / Year / Accomplishments (ifaleadership positionpleaseindicatehereand elaboratebelow) / Signature of
Coach/Advisor
9 / 10 / 11 / 12
Baseball / X / X / X / X / HighestAverage,20 Steals,Co-Captain / Mr.B Jefferson

II.Leadership Positions: List all elected or appointed leadership positions held in school, communityorworkactivities.Positionsinwhichyouwereresponsible fordirectingor motivatingothersshouldbeincluded.Forexample:elected studentbody;classorclub officer;committee chairperson;team captain; newspapereditor;work area manager;or communityleader.

Leadership
Position / 9 / Year
10 / 11 / 12 / Explanation / Signature of
Coach/Advisor
SpanishHonorSociety / X / President / Mrs. J Doe

III.CommunityService/Volunteerism:Listcommunity activitiesinwhichyouhaveparticipated andnoteanymajoraccomplishmentineach.Theseshouldbeanyactivitiesoutsideofschoolinwhich youparticipated forthebettermentofyourcommunity.Forexample:Churchgroups,clubssponsored outsidetheschool,BoyorGirlScouts,volunteergroups,orcommunityart endeavors.

Activity / 9 / Year
10 / 11 / 12 / Total No. Hrs. Worked / Explanation / Signature of
Supervisor
Habitatfor
Humanity / X / X / X / 20+9+10
=39 / Helped Build Houses for Poor
Families / Mr. T Smith

IV.RecognitionsandAwards:Listbelowany,honorsorrecognitionsthatyouhavereceivedwhich supportyourbidtobeselected formembershipintheNationalHonorSociety.

Recognitionor
Award / Year/ Grade / Explanation / Signature of
Coach/ Advisor
Kiwanis Honor
Athlete / 2007 / 11thgrade / Plaquecertificate awardedforthe
HighestGPAfora studentona team / Ms. Marie
Adams

V. Work Experience:List belowanyworkexperienceyouhave.Thismaybepaidorunpaid.

Job/ Location / Year / Duties / Supervisor
Cashier/ Pathmark / 7/2007 - 9/2008 / Ringupcustomersorders,restock shelves,andpricecheck / Mr.MarkPeters

VI.RequiredPersonalStatement:It is importantthat candidatesdevotetheirattentionto the personalstatement.Typeanessay(150-250words),whichhighlightsimportantexperiences and achievementsinyourhigh schoolyears. Asyouwrite, keepinmindthefourcornerstonesoftheNational HonorSociety:character,leadership,scholarshipandcommunityservice.

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Please readthefollowingstatementcarefully andsign:

Iunderstandthatthecompletionofthisforminnoway guaranteesmymembershipin TheNationalHonorSociety,but that I am being considered and reviewed for membership in accordance with the rules and regulations of The National HonorSocietyandthelocalchapter’sbylaws. Ihaveattended the mandatory information meeting and understand all instructions. IwillacceptthedecisionoftheFacultyCouncil charged with the responsibility of selecting new members as final.

I wish to be considered for membership.

I do not wish to be considered for membership at this time.

Student Name (Printed)Student SignatureDate

Parent SignatureDate

MIDDLETOWNHIGH SCHOOLNORTH NationalHonor Society

Martha Pennington Chapter

Community / School Service Record Form

Date:

Student Name:

Name of Organization:

Description of Services:

NumberofHoursThisMonth:

Total HoursAccumulated To Date:

Supervisor’s Name:

Supervisor’s Title:

Supervisor’s Phone # ( )

_-

_(If not a H.S. NORTH faculty member)

Supervisor’s Signature:

Submit this form to Mrs. Diercksen in 2127