Amery Chapter of the National Honor Society:
Student Membership Application
Directions: Please complete all sections. Do not be modest. Every bit of information supplied can be used by the
teacher selection committee to assist with the selection process. Completion of this form does not guarantee
selection into the National Honor Society, but you will not be considered unless it is turned in before the deadline,
which is October 7th by 3:30PM to Mrs. Kurtzhals in the Guidance Office. The sections below are divided into five
categories: curricular activities, leaderships, service, other awards/recognition and personal statement. Please try
to submit as much information as possible in each section. If you need more space to list more activities in the
application you may alter/modify the application to fit your additional information.
I. Administrative Information (Word process/type your application.)
Name & Grade Level:
II. Curricular Activities:
List all activities you have participated in during high school. Include activities such as clubs, sports teams,
musical lessons, 4-H, youth groups, boy/girl scouts, etc. and any major accomplishments in each. Curricular
activities are into two sections, school and community activities.
School Activity
9
10 11 12
(Examples: Basketball, Jazz Band, FBLA, School
Drama, etc.)
Community Activity
(Examples: 4-H. Scouts, Youth Groups, Private
Music Lessons, etc.)
Accomplishments
(Examples: Captain, attended regionals, scored a first, etc.)
9
10 11 12
Accomplishments
(Examples: Eagle Scout, 4-H Award at Fair, etc.)
III. Leadership: Leadership will be divided into two areas, elected positions and student leadership
Section A: Elected & Appointed positions
List all elected or appointed leadership positions held in school, community, or work activities. Only those
positions in which you were directly responsible for directing or motivating others should be included. For
example, elected to student council, club officer, committee chairperson, sports team captain or co-captain,
newspaper editor, work manager/trainer, church youth group officer, 4-H officer, etc.
Leadership Position
9
10 11 12
Accomplishments
Section B: Student Leader & Leadership Examples
Many students are leaders in various ways without ever being elected to a leadership position. In this section we
want you to describe how you are a leader in your classroom, school, and/or community. Student leaders are
resourceful, good problem solvers, idea contributors, dependable, and have a positive attitude about life. Below
list leadership qualities that you possess and then give examples of a time when you demonstrated this leadership
quality. Use as many of the spaces below that you desire, the more information you can provide the better.
Leadership Quality
Example that Demonstrates this Quality
Examples: Classroom Leader
Positive Attitude
Dependable
I often lead classroom discussions in my science class.
I encourage others in my classes and give compliments.
I always arrive to my job at Dairy Queen on time, and pick up shifts for others.
IV: Service: Service will be divided into two categories, community activities and work experience.
A. Community Service: List community activities in which you have participated and note any major
accomplishments in each. These should be any activities outside of the school day in which you participated for
the betterment of your community. For example, service through: church youth groups, clubs (Boy or Girl
Scouts), volunteer groups (Habitat for Humanity), or community wide events (Miss Amery Pageant.) You may
also list community service done through a school sponsored club/activity, but the service must take place outside
of the school day. An exception to the rule of service outside of the school day is Kinship, if you are a Kinship
mentor you should list that experience below as giving up your free time, lunch, is considered a service. You must
have the signature of an adult directly responsible for the activity you participated in, or your application
will be considered incomplete and you will not be accepted into NHS. Please try to have the signature be from
an adult other than a parent, unless your parent was directly responsible for that activity.
Community
Activity
Examples:
Salvation Army-FCCLA
Nursing Home Visits
Raked Leaves with
Youth Group
9 10 11 12
X
X
X
X
X
X
Hours &
Occurrences
Accomplishments
2 hours 1 time
1 hour every week
3 hours 2 times
Rang bells to raise money
Spent time with elderly patients
Helped elderly clean their yards
Signature of
Adult Sponsor
Signature of Adult here
Signature of Adult here
Signature of Adult here
V. Work Experience:
List below any job experiences you have had during high school that support your bid to be selected for
membership in National Honor Society. Work experience may be paid or volunteer. Work experience may
include some of the following types of activities: babysitting, farm work, lawn work, employment at a local place
of business, etc.
Job Position
9
10 11 12
Number of Hours on Job
Weekly
V. Other Awards and Recognitions: Please list any awards or recognitions, not already mentioned on this form,
that you have received during high school. Examples: Who’s Who Among High School Students nomination,
local art award, honor roll, etc.
Award or Recognition
Examples: Honor Roll
Voice of Democracy Competition
Poetry Award
Date & Grade Level Received
A honor roll all 4 terms of 9th grade year.
Second place, grade 10
A poem I wrote for English 9 was published in a student
magazine.
VI. Personal Statement: National Honor Society membership is based on scholarship, leadership, character and
service. Please type in the space below regarding how you exemplify these characteristics.

Please note that the overall neatness, spelling, appearance, etc. of this application will be a factor in the scoring of
your application.
Teacher Evaluation Form-1
To the Student: You received two teacher evaluation forms with this National Honor Society Packet. The teacher
evaluation form is intended to help the selection committee evaluate your character and leadership within the
classroom setting. See guidelines below on who you should select to fill out these forms on your behalf.
 Teacher Evaluation Form 1: You, the applicant, need to ask a classroom teacher that you had for a class
last school year, 2014-2015, to fill out this evaluation form.
 Teacher Evaluation Form 2: You, the applicant, may ask any other classroom teacher that you have had
previously during your high school career. For example, if you are a sophomore this would have to be a
teacher from last school year, freshman year, if you are a junior, this could be a teacher you had freshman
or sophomore year, if you are a senior this could be a teacher from freshman, sophomore or junior year.
You should not ask a teacher in a current class unless you also had them during a previous year.
We want teachers that have had you in class for at least one full term to complete the evaluation, not a teacher that
has only had you in class for a few weeks. The teachers you select to complete your evaluation forms should turn
in the completed forms to Mrs. Kurtzhals by Wednesday, October 7th. As the student, you are not to see the
completed evaluation forms, and so they should be handed in to Mrs. Kurtzhals separately from your application.
To the Teacher: Please complete this evaluation form on behalf of the National Honor Society applicant. This
information will be combined with the student application to aid the faculty selection committee. Please hand this
form into Mrs. Kurtzhals by Wednesday, October 7th.
Student Name: ___________________________________
Date Form Was Given to Teacher: ___________
Evaluated By: ___________________________________
Course: ________________________________
Teacher: Please evaluate the above listed student based on your experience with this student in your classroom.
Please circle one number on the scale below with 1 being low, 2 needs improvement, 3 average, 4 excellent, and 5
exceptional.
1. Does the student comply with your classroom rules?
1
2
3
4
5
4
5
2. Does the student demonstrate high standards of honesty?
1
2
3
3. Does the student show courtesy, concern, and respect for others in the classroom?
1
2
3
4
5
4
5
4. Does the student willingly accept criticism and recommendations?
1
2
3
5. Does the student exemplify desirable qualities of behavior such as cheerfulness, friendliness, and stability?
1
2
3
4
5
6. Does the student uphold principles of morality and ethics in the classroom?
1
2
3
4
5
Please feel free to share any additional comments regarding this student on the back of this form.
Teacher Evaluation Form-2
To the Student: You received two teacher evaluation forms with this National Honor Society Packet. The teacher
evaluation form is intended to help the selection committee evaluate your character and leadership within the
classroom setting. See guidelines below on who you should select to fill out these forms on your behalf.
 Teacher Evaluation Form 1: You, the applicant, need to ask a classroom teacher that you had for a class
last school year, 2014-2015, to fill out this evaluation form.
 Teacher Evaluation Form 2: You, the applicant, may ask any other classroom teacher that you have had
previously during your high school career. For example, if you are a sophomore this would have to be a
teacher from last school year, freshman year, if you are a junior, this could be a teacher you had freshman
or sophomore year, if you are a senior this could be a teacher from freshman, sophomore or junior year.
You should not ask a teacher in a current class unless you also had them during a previous year.
We want teachers that have had you in class for at least one full term to complete the evaluation, not a teacher that
has only had you in class for a few weeks. The teachers you select to complete your evaluation forms should turn
in the completed forms to Mrs. Kurtzhals by Wednesday, October 7th. As the student, you are not to see the
completed evaluation forms, and so they should be handed in to Mrs. Kurtzhals separately from your application.
To the Teacher: Please complete this evaluation form on behalf of the National Honor Society applicant. This
information will be combined with the student application to aid the faculty selection committee. Please hand this
form into Mrs. Kurtzhals by Wednesday, October 7th.
Student Name: ___________________________________
Date Form Was Given to Teacher: ___________
Evaluated By: ___________________________________
Course: ________________________________
Teacher: Please evaluate the above listed student based on your experience with this student in your classroom.
Please circle one number on the scale below with 1 being low, 2 needs improvement, 3 average, 4 excellent, and 5
exceptional.
1. Does the student comply with your classroom rules?
1
2
3
4
5
4
5
2. Does the student demonstrate high standards of honesty?
1
2
3
3. Does the student show courtesy, concern, and respect for others in the classroom?
1
2
3
4
5
4
5
4. Does the student willingly accept criticism and recommendations?
1
2
3
5. Does the student exemplify desirable qualities of behavior such as cheerfulness, friendliness, and stability?
1
2
3
4
5
6. Does the student uphold principles of morality and ethics in the classroom?
1
2
3
4
5
Please feel free to share any comments regarding this student on the back of this form.