SOMERVILLE MIDDLE SCHOOL

CHAPTER OF THE NATIONAL JUNIOR HONOR SOCIETY

STUDENT ACTIVITY FORM

Name:______Grade:______

Directions: Please complete all sections (type or print in ink). Do not be modest. All information is important to assist the Faculty Council in the selection process. Completion of this form does not guarantee selection. This form is due to the chapter advisors Mrs. Eckardt or Mrs. DePace by Friday, May 1stat 4:00 P.M. Additional sheets of paper listing your activities and accomplishments may be attached.

Co-curricular Activities: List all activities in which you have participated andcheck the grade level(s) indicating your involvement. Include clubs, teams, musical groups, etc. Note any major accomplishments in each. Please list the name of the adult supervisor who can verify your participation in each activity.

Activity 5 / 6 / 7 / 8 /

Accomplishments

/

Name of Adult Supervisor

Service and Leadership Positions: List service activities/organizations in which you have participated and check the grade level(s) indicating your involvement. These can be service projects done with a group either in or out of school, or done as individual projects performing service. Generally speaking, service activities are those that are done for or on behalf of others (not including immediate family members) for which no compensation (monetary or other) has been given. Please list the name of the adult supervisor who can verify your participation in each activity.

Office Held (if applicable) / Name of Activity
Organization / 6 / 7 / 8 /

Name of Adult Supervisor

Community Activities: List other community activities in which you have participated and check the grade level(s) indicating your involvement. Note any major accomplishments in each. These should be activities outside of school in which you participated for the betterment of your community for example: religious groups, clubs sponsored outside the school, Boy or Girl Scouts, or community art endeavors. Do not repeat participation already listed above. Please list the name of the adult supervisor who can verify your participation in each activity.

Community Activity / 6 / 7 / 8 /

Hours/Week

/

Major Accomplishments

/

Name of Adult Supervisor

NJHS Student Activity Form, page 2

Work Experience & Honors: List below any job experiences, honors, or recognitions that you have received which support your bid to be selected for membership in the National Junior Honor Society and check the grade level(s) indicating your involvement. Work experience may be paid or volunteer.

Activity / 6 / 7 / 8 /

Accomplishments

Additional information you may wish to include which would enable the committee to evaluate your qualifications.

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I understand that completion of this form does not guarantee membership and that I am being considered for membership in the National Junior Honor Society.

Student’s Signature:______Date:______

Parent/Guardian Signature:______Date:______

PLEASE RETURN FORM TO Mrs. Eckardt or Mrs. DePace

By Friday, May 1st at 4:00

No late applications will be accepted.