Dublin High School National Honor Society Application
Due Date: February 13, 2015 by 4:00 p.m. in the Counseling Office
Dublin High School Chapter of the National Honor Society
DIRECTIONS: PLEASE COMPLETE ALL SECTIONS. TYPE OR PRINT ALL INFORMATION AND SUBMIT IT BY
THE 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. RUBIO AT RUBIOCAROLINE@DUBLINUSD.NET.
ALL CANDIDATES SHOULD ALSO ATTACH AN UNOFFICIAL TRANSCRIPT TO THIS DOCUMENT.
TRANSCRIPTS CAN BE PRINTED OFF OF YOUR INFINITE CAMPUS PORTAL. STUDENTS BEING CONSIDERED
FOR NHS SHOULD HAVE NO “D” OR “F” GRADES ON THEIR TRANSCRIPT THAT HAVE NOT BEEN
REMEDIATED PRIOR TO SUBMISSION OF THIS APPLICATION.
1. Administrative Information
Name
Current grade level
ID number
2. Leadership Roles – 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 of the student
body class or club; committee chairperson; team captain; newspaper editor; work area manager; or
other community leader). Please include the name or the adult responsible for supervising your
leadership in each position.
Leadership Role
Grade
Level(s)
Activity/Organization
Supervising Adult
3. 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 otherwise) has been given. Please ask an adult supervisor who can verify your
participation in each activity to sign on the appropriate line, and also list the estimated number of hours
you invested while performing this service. Please note that per our chapter requirements, candidates
must complete a minimum of 10 service hours per semester in order to maintain membership. For
initial consideration, students should have performed at least 10 hours of community service at the time
of candidacy.
Activity
Grade Level(s)
Hours of
Service
Supervising Adult
4. 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.
Activity
Grade
Level(s)
Accomplishments
5. 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 Girl Scouts, community art endeavors, etc.). Do not repeat participation already listed
above. Please include the name of the adult supervisor of each activity.
Year Community
Activity
9
10
11
12
Hours Accomplishments
Supervising Adult
6. 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.
Year Job, Recognition or
Award
9
10
11
12
Group or
Activity
Hours Spent (if
applicable)
Supervising Adult
Compliance with Dublin High School Chapter Standards:
A.
I certify that I have earned a 3.75 GPA or above and have no D/F grades in any course that I have not
remediated.
B. I affirm that I have been in compliance with the honor code and have no incident of cheating or
plagiarism. I adhere to a strict code of personal ethics, which are also mirrored by the Dublin High School
Honor Code.
C. I understand that any incident of suspension or expulsion or an incident of plagiarism or cheating may
exclude me from candidacy or membership with the National Honor Society.
D. I commit to performing, in an ongoing basis, 10 hours of community service per semester.
E. I understand that there is a $10 dues fee due each calendar year, payable once I have been admitted to
the Dublin High School chapter of the National Honor Society and payable within the first 30 days of the
first semester of the school year or at the first general meeting of the current school year. Failure to meet
my financial obligation for ongoing membership may jeopardize my membership in NHS.
F. I commit to attending all scheduled meetings related to the chapter as well as specific committee
meetings if on that committee. Each member is allowed two discretionary absences.
G. I will participate in activities sponsored by the DHS chapter.
H. All current members and candidates who are being inducted are required to attend the Induction
Ceremony. New candidates are not official members until inducted in to the chapter.
I. I will subscribe to a personal code of conduct reflecting of the guiding principles of the NHS and will treat
others with kindness and respect. My personal conduct will be above reproach both in and outside of
school.
J. If I am not chosen for induction, I have the right to a hearing with the Faculty Council to appeal my case.
In order for a student to be selected for membership to the National Honor Society, a majority vote in favor or
membership by the Faculty Council is required. A decision is made only after a thorough review of each applicant’s
candidacy, and candidacy is not solely determined due to academic GPA. Students who are not selected will be
notified in writing and an appeal may be considered if provided to the Faculty Advisor within 30 days.
7. 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/we have reviewed the full Candidate Information Packet provided to us by the chapter. In addition, I/we have
read the information submitted by my son/daughter on this form and can verify that it is tru, accurate, and
complete.
Parent signature:_____________________________________________Date:_____________________
Preferred method of contact (check one and fill in the blank):
_____Parent phone number(s):___________________________________________________________
_____Parent e-mail:____________________________________________________________________
We request this contact information so that we can notify you regarding important details.
Return this completed form to the Dublin High School Counseling Office, care of Mrs. Caroline H. Rubio.