Leesville Road High School Chapter of the National Honor ...
Leesville Road High School Chapter of the National Honor Society
STUDENT ACTIVITY INFORMATION FORM
Due Date: WEDNESDAY, MAY 1, 2013 BY 3:00 IN ROOM 117 OR 131
Directions: Please complete all sections by typing or writing with blue or black ink. All provided information will be used by the Faculty Council to assist with the selection process. Completion of this form does not guarantee selection. Please be aware that Mr. Davis and Mrs. Engdahl, NHS Advisers, are not voting members of the Faculty Council. This form must be submitted by 3:00 p.m. on or before the due date. Late or incomplete forms will not be considered.
I. Administrative Information (please type or print)
Name: __________________________________________________________________________________________
First Middle Last
Parents’ Name(s): _________________________________________________________________________________
Address: ________________________________________________________________________________________
1st period room #: ________________ 1st period teacher’s name: __________________________________________
II. Co-curricular Activities (LRHS-Sponsored Activities and Student Initiated Activities): Eligible clubs are those that were established before October of the current school year.
List all activities in which you have participated during high school. Include clubs, teams, musical groups, etc., and major accomplishments in each.
|Activity |Year |Accomplishments |Name of Adult Sponsor |Signature of |
| | | | |Adult Sponsor |
| |9 |10 |11 | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
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III. Leadership Positions:
List all the elected or appointed leadership positions you have held or currently hold at Leesville Road High School and outside of school. Please do not list positions you have been elected to for next school year. Only those positions in which you are directly responsible for directing or motivating others should be included. These are positions that are actively sought after by the student, not required by a class.
Examples include:
• elected student body, class, or club officer
• committee chairperson
• team captain
• newspaper or yearbook editor
• Eagle Scout
|Leadership Position |Year |Activity or Organization |Name of |Signature of |
| | | |Adult Sponsor |Adult Sponsor |
| |9 |10 |11 | | | |
| | | | | | | |
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(Required) In the space below, please explain as specifically and briefly as possible what you did in each leadership position to “direct or motivate others.” You may attach additional paper if needed.
IV. Service
List all community service in which you have participated over the past nine months and note any major accomplishments in each. These should be any activities outside of school in which you participated for the betterment of your community. Please provide documentation that you completed each service activity.
|Community |Year |Description and dates of Service |Name of Adult Sponsor |Signature of |
|Activity | | | |Adult Sponsor |
| |9 |10 |11 | | | |
| | | | | | | |
| | | | | | | |
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V. Discipline Record
Have you ever been the subject of disciplinary action at Leesville Road High School or publically. This includes but is not limited to; lunch detention, after school detention, suspension, citations, arrests. Please list and describe in the space provided below.
National Honor Society
Membership Requirements
While a member of National Honor Society at Leesville Road High School, I understand and accept the following annual requirements for membership:
• Uphold the ideals of National Honor Society, including leadership, scholarship, service, and character
• Attend all NHS functions and meetings, unless excused by prior written notice
• Maintain an unweighted 3.6 cumulative GPA
• Perform 30 hours of service yearly
• Pay dues in an amount designated by the chapter constitution ($20.00)
• Participate in designated service projects for the LRHS chapter of NHS.
• Perform duties designated by officers and advisers which will benefit the chapter and community.
I understand that if I do not fulfill these requirements that I may be placed on probation and/or dismissed from National Honor Society. I understand that if a member is dismissed from National Honor Society he/she may not become a member of National Honor Society again.
Student name: Date:
Student signature: Date:
Parent name: Date:
Parent signature: Date:
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10th Grade
11th Grade
(Circle your grade.)
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