Student Activity Information Form (This is NOT an application form.)
Directions: Please
complete all sections. Type all
information and submit by published deadline. Do not be modest. Every bit of
information will be used by the Faculty Council to assist with the fair
consideration of your candidacy during the selection process.
Completion and
submission of this form does not guarantee selection. Should you have questions about this form, please contact Mrs.
Crutcher, NHS advisor.
I. Administrative Information
Name:
Current Grade Level:
II. Leadership Positions—List all elected or appointed leadership positions or other positions of responsibility held in school, community, or work activities. Only those positions in which you were responsible for directing or motivating others should be included (e.g., elected officer for the student body, or club; committee chairperson; team captain; newspaper editor; work area manager; or other community leader). Please include the name of the adult responsible for supervising your leadership in each position. (Add more lines if needed.)
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Leadership Positions |
Activity/ Organization |
9 |
10 |
11 |
12 |
Supervising Adult |
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III. Service Activities—List service activities in which you have participated. These can be individual or group service projects done either in or out of school. Generally, 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 ask an adult supervisor who can verify your participation in each activity to sign the appropriate line, and also list the estimated number of hours you invested while performing this service. (Add more lines if needed.)
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Activity |
Hours of Service |
9 |
10 |
11 |
12 |
Supervising Adult Signature |
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IV. Other Student Activities—List all other school-based activities (not noted above) in which you have participated in school. Include clubs, teams, musical groups, etc. and any significant accomplishments in each. (Add more lines if needed.)
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Activity |
9 |
10 |
11 |
12 |
Accomplishments |
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V. Other community activities—List other 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 (e.g., religious groups, clubs sponsored outside the school, Boy or Girls Scouts, community art endeavors, etc.) Do not repeat participation already listed above. Please include the name of the adult supervisor of each activity. (Add more lines if needed.)
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Community Activity |
Hours |
Accomplishments |
9 |
10 |
11 |
12 |
Supervising Adult |
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VI. Work Experience, Recognition, and Awards—Though not a specific criterion for membership, please list below any job experiences, honors, or recognition that you have received that support your candidacy for membership in the Honor Society. Work experience may be paid or volunteer. (Add more lines if needed.)
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Job,
Recognition or Award |
Group or Activity |
Hours Spent on Job or Activity (if applicable) |
9 |
10 |
11 |
12 |
Supervising Adult |
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VII. Signatures
I understand that completing and submitting 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
_________________________________________Parent phone number(s)
We request this so that we can notify you regarding important details.
Return completed form to Mrs. Crutcher, Room 13.
Indian Creek High School
506 S. Shabbona Rd.
Shabbona, IL 60550
815-824-2197
If you have any questions about this form or membership in general, please contact Mrs. Crutcher at the above address or phone number. You may also email her scrutche@kidsroe.org