NHS Interest Form Fall 2013.docx



YWLANational Junior Honor Society Interest Form-57150-189865Fill out forms completely and return them to Mrs. Church by 3:55pm Monday, November 4th. Forms must be typed and printed.Return in this order, with a single staple: This form (typed)Leadership Positions (typed)Service Activities (typed)Your essay (typed)Parent Verification (signed)Contract and Agreement (signed)Teacher recommendation information (signed)Copy of your MOST recent report card. Submitted by other parties on your behalf:Teacher Recommendation Forms (2)Assistant Principal Signature FormPlease complete all sections. Save a copy of this document on your own google account to work with. 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 of this form does not guarantee selection. Should you have questions on this form, please contact Mrs. Church (Marissa.Church@). (Keep resume to your Middle school years only!)I.STUDENT INFORMATIONName :Grade:Email Address:Phone Number:Parent Name:Parent Phone Number:II.LEADERSHIP POSITIONSList all elected or appointed leadership positions you held in school, community or work activities. Only those positions in which you were responsible for directing or motivating others should be included. For example: elected officer for student body, class 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. No adult signature is needed in this section. An example is given. Please follow the provided format.Grade Leadership PositionActivity / OrganizationName of Supervising Adult6TH (ex.)Co-CaptainCo-LeaderVice PresidentSwim TeamSpanish ClubStudent SenateCoach JohnsonMr. PuebloMrs. McGovern7th8thIII.SERVICE ACTIVITIESList service activities in which you have participated. These can be individual or group service projects done either in or out of school. Generally speaking, service activities are those that are done for or on behalf of others (not including immediate family members or neighbors) for which no compensation (monetary or other) has been given. Please ask an adult supervisor who can verify your participation in each activity (not an immediate family member) to sign on the appropriate line and also list the number of hours you invested while performing this service. Yes, adult signature needed! See the attached sample as to how to type your responses. Please use the given format. Grade ActivityHours of ServiceName of Supervising Adult AND SIGNATURE6TH (ex.)Tutored for Curious KidsHabitat for Humanity820Mrs. KinderwatchMrs. KinderwatchMr. HausenMr. Hausen7TH 8thIV.ESSAYPlease type below a ONE-PAGE, DOUBLE-SPACED, TYPED essay.In this essay, please answer the following:”Why do you want to be a member of the National Junior Honor Society?”V.PARENT VERIFICATIONI understand that completing this form does not guarantee selection to the National Junior 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 (see attached contract in following pages) and to fulfill all of my membership obligations to the best of my ability.I also understand that the National Junior Honor Society is dedicated to selecting students based on the categories of Scholarship, Citizenship, Leadership, and Service. A student must be determined to be exemplary in all categories by the entire Faculty Selection Committee as reflected in their interest form and in-school performance. National Junior Honor Society is not an “honor roll.” Each student will be evaluated based on the same standards of merit and information sources.Furthermore, I understand that recommendations and comments made in confidence by members of the faculty and staff will be kept confidential, and will only be considered valid for determining student acceptance when submitted through the proper channels of evaluation. I understand that all membership decisions are submitted to and approved by the Principal, Mrs. Hall, prior to student notification.Student Signature______________________________________________I have read the information provided by my student on this form and can verify that it is true, accurate and complete.Parent Signature_____________________________Date______________VI. YWLA NATIONAL JUNIOR HONOR SOCIETY CONTRACT & AGREEMENT?By signing the statement below, I agree to abide by the terms written here in order to remain in "good standing" in Young Women's Leadership Academy chapter of the National Honor Society.I will follow YWLA's Code of Conduct, as outlined in the student handbook. If I am in violation of?the handbook and/or if I receive either a In House Suspension or an Out of School Suspension as a result of that violation, I realize that I may be subject to removal from the National Junior Honor Society, based on the discretion of YWLA Faculty Council.??If dismissed from NJHS, I realize that?I will not be able to wear the traditional NJHS regalia for the remainder of the year and will not be eligible to list NJHS on scholarship applications. I also agree?to complete?at least ten (10) hours of community service activities. Five (5) of these hours may have been completed during the summer prior to the academic school year. Five (5) hours must be completed during the academic school year.? These ten (10) hours must be spread out over at least three different types of community service or volunteer activities.? I may not count more than 5 (5) hours for one activity without permission of the NJHS advisors. I also agree to log and record all service hours?in detail with dates, times, descriptions of events and phone numbers & names of contact persons on the provided form.? This form is to be turned in within two (2) weeks of event date in order for the hours to count toward the minimum. If this form is not turned in within two (2) weeks after participation in the event, I realize that I will not be able to count these hours towards my total minimum. Donations for Service Learning DO NOT COUNT. If I fail to complete ten hours of community service, by the deadline posted on the NJHS website, I may be dismissed from National Junior Honor Society.If I fail to maintain the required 96 or higher, I will be placed on probation for a semester. If my GPA does not return to the minimum 96 or higher after one semester of probation, I may be removed from NJHS.If I earn more than 2 demerits per six weeks I understand that I may be placed on probation and I realize that continuous demerits may make me subject to removal from the YWLA chapter of NJHS/NHSRepeated absences from meetings or failure to report to committed community services events or failure to complete required service hours could result in dismissal from NJHS, as decided by YWLA National Honor Society Faculty Council.???I agree to the terms above.Printed Name____________________________________________Student Signature_________________________________________Parent Signature__________________________________________VII.TEACHER RECOMMENDATION FORMSWrite your name on both of the attached recommendation forms. Ask a staff member who knows you well to fill out the form on your behalf. Give a form to two different staff members. Ask the teacher to please sign their name on your signature page. The staff member will complete the separate form and he/she will return it to the Mrs. Church. You SHOULD NOT see the form after you give it to the person recommending you. Student Name:________________________________________________I agree to complete and submit a teacher recommendation form for the above student and submit it directly to the guidance office.Teacher Name 1 (print)_______________________________________________Teacher Signature 1 _______________________________________________Teacher Name 2 (print)_______________________________________________Teacher Signature 2 _______________________________________________VI.Dean of Student’s or Dean of Instruction’s SIGNATUREFill out your name and grade level.Name:_______________________________ Grade____________Take this form to your grade-level principal. The principal will complete this form and submit it directly to Mrs. Church.Has this student ever been in violation of the YWLA Student Code of Conduct?Yes ________ No ________ If “yes”, please explain below, in detail.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you recommend this student for NHS membership? Yes ____ No ____ Student not known well enough to comment ______What are the first words that come to your mind in regards to this student (if you know him/her well)? Dean’s Signature Signature______________________________________Date___________NATIONAL JUNIOR HONOR SOCIETYTeacher Recommendation #1Student:Bring this form to a teacher or faculty member of your choice here at YWLA. Fill out your name and the recommending teacher’s name. Ask the teacher to complete the form by Monday, November 4th and to return it to Mrs. Church.Teacher:Your recommendation will be used to help the advisory committee select candidates for The National Junior Honor Society. This form is intended to assess the student’s character. This information is confidential! This form should be returned to Mrs. Church by Monday, November 4th. Do not return to student as the student should not see the completed form.Please respond to this recommendation as honestly as possible.STUDENT NAME (print):____________________________________________TEACHER RECOMMENDING (print):____________________________________________PLEASE ADHERE TO THIS RUBRIC AND USE IT CAREFULLY. THANK YOU.12345N.O.LowAverageGoodGreat (top 5% this year)Superb (top 5% of all time)Not ObservedATTENDANCE12345N.O.“I WILL HELP ATTITUDE”12345N.O.INTEGRITY12345N.O.HONESTY12345N.O.SELFLESSNESS12345N.O.RESPONSIBILITY12345N.O.CHARACTER12345N.O.LEADERSHIP12345N.O.CONCERN FOR OTHERS12345N.O.Feel free to add any and all comments that support the candidate on the back of this form. Please be specific. Thank you.Teacher Signature________________________________________________NATIONAL JUNIOR HONOR SOCIETYTeacher Recommendation #2Student:Bring this form to a teacher or faculty member of your choice here at YWLA. Fill out your name and the recommending teacher’s name. Ask the teacher to complete the form by Monday, November 4th and to return it to guidance.Teacher:Your recommendation will be used to help the advisory committee select candidates for The National Junior Honor Society. This form is intended to assess the student’s character. This information is confidential! This form should be returned to Mrs. Church by Monday, November 4th. Do not return to student as the student should not see the completed form.Please respond to this recommendation as honestly as possible.STUDENT NAME (print):____________________________________________TEACHER RECOMMENDING (print):____________________________________________PLEASE ADHERE TO THIS RUBRIC AND USE IT CAREFULLY. THANK YOU.12345N.O.LowAverageGoodGreat (top 5% this year)Superb (top 5% of all time)Not ObservedATTENDANCE12345N.O.“I WILL HELP ATTITUDE”12345N.O.INTEGRITY12345N.O.HONESTY12345N.O.SELFLESSNESS12345N.O.RESPONSIBILITY12345N.O.CHARACTER12345N.O.LEADERSHIP12345N.O.CONCERN FOR OTHERS12345N.O.Feel free to add any and all comments that support the candidate on the back of this form. Please be specific. Thank you.Teacher Signature________________________________________________ ................
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