STUDENT ACTIVITY INFORMATION FORM
for the National Honor Society
Directions: Please complete all sections Do not be modest. All of the information will be used
by the NHS Faculty Council to assist with the selection process. Completion of this form does
not guarantee selection. This form must be completed and returned to Mrs. Short in the library
media center by 2:15 on Tuesday, March 4. All information on this form must be either typed
or printed in blue or black ink. Do not create your own version of this form.
I.
ADMINISTRATIVE INFORMATION:
Name:___________________________________________________________________
Email Address:____________________________________________________________
Home Address:____________________________________________________________
Phone Number:____________________________________________________________
Year of Graduation:_________
II.
NHS QUALIFICATIONS:
A. Scholarship: you must maintain a GPA of 3.600 or higher (GPA not rounded).
B Leadership: you hold an elected or appointed leadership position in school, the
community, or at work in which you are directly responsible for motivating your peers
(age l3 or older).
C Service: you have performed at least twenty (20) verified hours of community service
for school, community, or religious organizations.
D. Character: you have displayed outstanding character traits such as honesty, integrity,
respect for others, etc. (Any disciplinary offense, infraction of school rules and/or
improper conduct may be cause for rejection)
III.
LEADERSHIP POSITIONS:
List all elected or appointed leadership positions held in an ongoing activity either at
school, in the community, or at work. The NHS defines leadership as: "All elected or
appointed leadership positions held in school, community, or work activities in which
the candidate is directly responsible for motivating his/her peers (age l3 or older)."
Examples of leadership positions include being class or club officer, committee
chairperson, team captain, newspaper editor, work area manager, or community leader.
For each activity, please attach a detailed letter that lists your position and
responsibilities, and illustrates with examples your role as a leader. This letter should
have the signature of the adult who is your supervisor or advisor, agreeing with what
you have written (parents are not allowed to sign off as testament to your leadership
experience). You must also include the phone number and/or email of this adult. If you
have any questions, please see Mrs. Ingerslev, Mrs. Short or one of the NHS faculty
council members. Please note that you cannot count the same item toward both the
Leadership and Service requirements.
LEADERSHIP POSITION
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ACTIVITY OR ORGANIZATION
STUDENT ACTIVITY INFORMATION FORM
for the National Honor Society
IV.
SERVICE:
List all service activities in which you have participated during your high school career
and note any major accomplishment in each. These should include any activity either
inside or outside the Westford Public School system in which you participated for the
betterment of your community. For example: church groups, clubs sponsored outside of
school, Boy or Girl Scouts, volunteer groups, or community/religious projects all
constitute service. Please obtain signature of adult sponsor. Please note that you cannot
count the same item toward both the Leadership and Service requirements.
SERVICE ACTIVITY
V.
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Dates and Hours
ACCOMPLISHMENT
SIGNATURE
CHARACTER:
Personal Testament:
I testify that I have consistently demonstrated personal integrity and such characteristics
as reliability, honesty and sincerity both in my academic and personal life.
Your signature______________________________
The following affidavit is to be signed by your Dean and three (3) faculty members at
Westford Academy who know you well:
In my opinion (Print Your Name)__________________________meets the
requirements of CHARACTER necessary for membership in the Tadmuck Chapter of
the National Honor
Society.
Dean:______________________________________
Faculty:____________________________________
_____________________________________
_____________________________________
VI.
Write a short essay (two page maximum) answering the question, “How do you
demonstrate the four pillars of the National Honor Society in your life?” The four
pillars are scholarship, service, leadership and character. This must be typed, double spaced, and attached to this form.
I understand that if I am notified of an unfavorable decision on my application for membership
that I have 3 SCHOOL DAYS to notify the NHS advisors in writing of my intent to APPEAL
the NHS Faculty Council decision.
I certify that all the information in this form is truthful.
YOUR SIGNATURE___________________________