St. Paul’s Lutheran School’s National Junior Honor Society

Prospective Member Selection Activity Form

Directions: Please complete all sections. Type or print all information and submit it bythe published deadline. Do not be modest. Every bit of information will be used by theFaculty Council to assist with the fair consideration of your candidacy during theselection process. For a more detailed description of what is being considered for eachcategory, please refer to the guidelines included in this packet.

Completion and submission of this form does not guarantee selection. Should you havequestions about this form, please contact Mrs. Fink

I. Administrative Information

First and Last Name ______

Circle Current Grade Level: 6 7 8

II. Leadership Positions: List all elected or appointed leadership positions or otherpositions of responsibility held on and off campus. Be sure to fill in all leadershippositions that relate to you. Please include the adult responsible for supervising yourleadership in each position and the time in which you served in that role.

* = List otherleadership positions you have held.

Leadership Position / Activity/Organization / Date(s) / Supervising Adult
Vacation Bible School
Servant Leadership
Chapel Technician
Boy/Girl Scouts
Band
Children’s Ministry
Chapel Leaders
Athletics (Captain)
Peer Tutoring
MSWB
*
*
*
*
*
*

III. Service Activities: Service is considered to be those actions undertaken by thestudent which are done with or on the behalf of others without any direct financial ormaterial compensation. Please describe any/all activities that you have participated inthis past year where you have served others using some or all of the following qualities:Volunteers and provides dependable and well-organized assistance, has a service-orientedattitude of working well with others, mentors persons in the community or students, andshows a courtesy by assisting visitors, teachers, and students. Please ask an adultsupervisor who can verify your participation in each activity to sign on the appropriateline.

Activity: ______Date: ______

Description: ______

______

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Adult Supervisor’s Signature ______

Activity: ______Date: ______

Description: ______

______

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Adult Supervisor’s Signature ______

Activity: ______Date: ______

Description: ______

______

______

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IV and V. Citizenship and Character Activities: These two areas will be evaluated bythe Faculty Counsel reviewing the prospective member’s Middle School records(academic, conduct/behavior, and administrative).

VI. Letter of Recommendation: Please include a letter of recommendation. This letter can come from acoach, Pastor, or group leader.

VII. Signatures:

I understand that completing and submitting this form does not guarantee selection to theNational Junior Honor Society. I attest that the information presented here is completeand accurate. If selected, I agree to abide by the standards and guidelines of the St. Paul’s Lutheran School’s NJHS Chapter and to fulfill all of my membership obligationsto the best of my ability.

Student Signature: ______Date_____

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

Parent Signature ______Date_____

Parent Phone Number(s) ______

(We request this so that we can notify you regarding important details)

Return completed form by the published deadline to the box in the front office.

Due: February 3rd, 2017

If you have questions about this form or membership, please contact Mrs. Fink

St. Paul’s Lutheran School National Junior Honor Society

Opt-Out Form

This form should be used in the case that a prospective St. Paul’s NJHS candidate wishesnot to participate in the selection process for this round (1st Semester 2014). Please turnit in to the box in the front office before the published deadline.

I, ______(please print full name),respectfully decline this invitation to be considered for the St. Paul’s NJHS for thisround.

Please check one of the boxes below, sign and date in the space below:

I wish to be considered for the next round, providing I meet the required cumulative GPA

I do not want to be considered for any other rounds while at St. Paul’s

______

Student Signature Date

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Parent SignatureDate