NATIONAL HONOR SOCIETY
Shell Lake High School
271 Highway 63 S.
Shell Lake, WI 54871
Student Activity Information Form
Note: Completion of this form does not guarantee selection.
Name:
Application Deadline: Thursday April 30, by 3:30 pm.
Candidate No. __________
Page 2
Directions
1.
This form must be typed.
2.
Complete all sections. Do not be modest. You may include paid work positions. If you need
more spaces, use additional pages. All information you provide will be used by the faculty council
to assist in the selection process.
3.
Note that signatures and explanations are required for certain areas.
Co-Curricular Activities
List all activities in which you have participated during high school. Include clubs, teams, musical groups,
etc., and major accomplishments in each. (NOTE: Detail the accomplishment in each activity.)
Co-Curricular Activities
Activity
9
10 11
12
Accomplishments
Candidate No. __________
Page 3
Leadership 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: Student Council member, class or club officer, committee chairperson, team captain,
newspaper editor, work area manager, or community leader.
Leadership Positions
Activity
9
10 11
12
Position
Candidate No. ____________
Page 4
Community and Service Activities
List community activities and the approximate number of hours involved in each activity. These should be
activities outside the school in which you participated for the betterment of your community. Use activities
performed through church groups, club sponsored outside the school, Boy or Girl Scouts, Chamber of
Commerce activities, volunteer hours at a nursing home, etc. You may include paid work positions.
(NOTE: An advisor or leader in charge of each activity must sign.)
Community Activities
Activity
9
10 11 12
No. of Hours
Signature
Candidate No.__________
Page 5
Recognition and Awards
List any special recognition or awards that have been bestowed upon you. Do not attach certificates, etc.:
simply list the area of recognition or award.
Activity
9
10 11
12
Position
Candidate No. ___________
Page 6
Essay
In 250 words or less, typed on a separate sheet of paper, describe why it is important that you be awarded
the honor of membership in the National Honor Society and how membership in the Society will benefit
you. In the essay, address the four components of membership (i.e., scholarship, leadership, service, and
character.) (NOTE: Content and mechanics of the essay will also be evaluated.)
National Honor Society Character Information (attached form)
The form on the following page must be completed by three individuals and returned by Thursday,
April 30, 2015.
Fill out the top portion of the form and then hand the form to one person in each of the following
categories. You must select one person from each category. You cannot select two persons from one
category and skip another.
Academic teacher (Core curriculum areas such as English, Math, Social studies, Science)
Vocational teacher (vocational subject, music, non-core)
Coach / Advisor
National Honor Society Character Information*
Student Name: ________________________
Date: ________________________
Teacher Name: ________________________
Subject: ______________________
Directions: Each faculty member should complete this rating scale, sign it, and return it in a sealed
envelope to the National Honor Society Advisor. Check only one rating for each quality.
Superior
5
Above
Average
4
Average
3
Below
Average
2
Poor
1
Respect for self and others
Responsibility in tasks undertaken; and for
own actions
Trustworthiness when given information or
duties
Fairness in dealings with others, like or unlike
self.
Caring demonstrated in interactions with
others, and for others
Citizenship demonstrated through appropriate
school and community behaviors.
Column Totals
Grand Total: ________
________________________________________________
(Teacher Signature)
____________________________
(Date)
Please return this confidential form to Mrs. Behilng no later than Thursday April 30, 2015.
Based upon “Six Pillars of Character”, NHS Handbook
National Honor Society Character Information*
Student Name: ________________________
Date: ________________________
Teacher Name: ________________________
Subject: ______________________
Directions: Each faculty member should complete this rating scale, sign it, and return it in a sealed
envelope to the National Honor Society Advisor. Check only one rating for each quality.
Superior
5
Above
Average
4
Average
3
Below
Average
2
Poor
1
Respect for self and others
Responsibility in tasks undertaken; and for
own actions
Trustworthiness when given information or
duties
Fairness in dealings with others, like or unlike
self.
Caring demonstrated in interactions with
others, and for others
Citizenship demonstrated through appropriate
school and community behaviors.
Column Totals
Grand Total: ________
________________________________________________
(Teacher Signature)
____________________________
(Date)
Please return this confidential form to Mrs. Behilng no later than Thursday April 30, 2015.
* Based upon “Six Pillars of Character”, NHS Handbook
National Honor Society Character Information*
Student Name: ________________________
Date: ________________________
Teacher Name: ________________________
Subject: ______________________
Directions: Each faculty member should complete this rating scale, sign it, and return it in a sealed
envelope to the National Honor Society Advisor. Check only one rating for each quality.
Superior
5
Above
Average
4
Average
3
Below
Average
2
Poor
1
Respect for self and others
Responsibility in tasks undertaken; and for
own actions
Trustworthiness when given information or
duties
Fairness in dealings with others, like or unlike
self.
Caring demonstrated in interactions with
others, and for others
Citizenship demonstrated through appropriate
school and community behaviors.
Column Totals
Grand Total: ________
________________________________________________
(Teacher Signature)
____________________________
(Date)
Please return this confidential form to Mrs. Behilng no later than Thursday April 30, 2015.
* Based upon “Six Pillars of Character”, NHS Handbook