VISTA MURRIETA HIGH SCHOOL
CHAPTER OF THE NATIONAL HONOR SOCIETY
Student Survey 2015-2016
Directions: Please complete all sections of this survey using your high school experience only. TYPE all information and submit it by the
published deadline. Do not be modest. All information will be used by the NHS faculty council to evaluate your candidacy during the selection
process. Completion of this form does not guarantee selection. Should you have questions about this form, please contact the NHS Faculty
Advisor by email: Ms. Lê – tle@murrieta.k12.ca.us
DEADLINE: FRIDAY, OCTOBER 16, 2015 BY 3:00 P.M.
I.
ADMINISTRATIVE/DEMOGRAPHIC INFORMATION (PLEASE PRINT CLEARLY)
Name:_______________________________________________ Student ID Number:_______________ Date Submitted:__________
Last
First
Middle
Mailing Address: ________________________________________ _______________ CA ____________ D.O.B ___/____/________
Street No. /P.O. Box
City
Zip Code
Home phone: (_____)______________ Cell phone: (_____) ____________ Texting? ____ Parent day phone: (____) _______________
Parent Email: ___________________________________ Student Email: ________________________________________________
Parent Names: (Please Print) _____________________________________________________________________________________
Cumulative Academic GPA (MUST have a minimum 4.0):_____________Grade Level (MUST be grades 10 or 11): ___________
II.
SIGNATURES (sign in blue or black ink!)
I understand that completing 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: _______________
III . STUDENT RECOMMENDATIONS (accounts for 20% of overall rating)
PRINT OUT 3 RECOMMENDATION FORMS FROM THE NHS LINK ON MS. LÊ’S WEBSITE.
Submit 3 student RECOMMENDATIONS to your teachers, staff members, or club advisors. Be certain to choose someone who can evaluate
your character and leadership ability. Recommendations ARE NOT to be returned to the student candidate but rather should be directed to the
NHS Faculty Advisor, Ms. Lê (Room EE15) in a confidential manner. Surveys WITHOUT the correct number of recommendations WILL
NOT BE CONSIDERED.
IV.
LEADERSHIP POSITIONS (ACCOUNTS FOR 30% OF OVERALL RATING)
List all leadership positions held in school and in your community. Leadership positions may be elected, appointed, or volunteered. Only those
positions in which you were responsible for directing or motivating others should be included. Include the name and contact number of the adult
responsible for supervising your leadership in each position. Circle a grade level at the time of the leadership activity.
Grade Level Leadership Position
Activity or Organization
Supervising Adult Name/Contact #
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
V.
SERVICE ACTIVITIES (ACCOUNTS FOR 30% OF OVERALL RATING)
Service activities are those that are done on behalf of others (excluding immediate family members) for which no compensation (monetary or
other) has been given. Activities can be individual or group service projects done either in or out of school. You must indicate the number of
hours (round up to nearest 10) and collect signatures of adult supervisors who can verify your participation in each activity. Circle your grade
level at the time of the service activity.
Grade Level
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
Activity
Hours of Service
Supervising Adult Name/Contact#
VI.
EXTRACURRICULAR ACTIVITIES (ACCOUNTS FOR 20% OVERALL RATING)
List all other school-based and community activities that have not yet been listed. Include clubs, team sports, musical groups, organizations,
Scouts, religious activities, community art endeavors, etc. Do not repeat activities/positions already listed in service or leadership
categories. Circle your grade level at the time of the extracurricular activity.
Grade Level
9 10 11 12
Activity
Accomplishments
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
RETURN COMPLETED FORM AND THREE RECOMMENDATION FORMS (STAFF WILL SUBMIT TO MS. LÊ ) TO THE NHS
ADVISOR (MS. LÊ – EE15)
DEADLINE: FRIDAY, OCTOBER 16, 2015, BY 3:00 P.M. IN ROOM EE15 – NO EXCEPTIONS!
VII. STUDENT ESSAY
Each Candidate is required to provide a personal essay of 750 words to the NHS Faculty Council that explains why the
candidate believes he or she should be considered for the National Honor Society and what contribution he or she would
contribute to an organization that lives out the four qualities of Scholarship, Service, Character and Leadership on the
VMHS campus.
The essay should be typed in the MLA format with a formal student header and a signature and date at the end of the piece.
ALWAYS SIGN IN BLUE OR BLACK INK.
Sample Student Header:
Smart Student
Student 1
Ms. Lê
National Honor Society
17 October 2014
Nation Honor Society Consideration Essay (Word Count = 750 words)
The essay should be submitted with the survey form by the DEADLINE: FRIDAY, OCTOBER 16, 2015, BY 3:00
P.M. IN ROOM EE15 – NO EXCEPTIONS!