NATIONAL HONOR SOCIETY
Needham High School
Mercy T. Cevallos and Ann Perham, Co-Advisors
Student Information Sheet & Application
NAME in full: ......................................
Assigned Number...........
All the information I have provided is true and accurate.
DATE .........................
Signature......................................................
Homeroom ..................
Phone Number ............................................
E-mail …………………………………………..
DO NOT WRITE your NAME on any page of this application, nor detach this cover page from the
packet. To ensure anonymity, we have assigned you a random number. The Committee members will not
know whose application they are reviewing; the only ones who will have that information are Ms. Cevallos
and Mrs. Perham, co-advisors to the Society, who do not have a vote.
DIRECTIONS Please read ALL information thoroughly to ensure that your TYPED application is filled
out completely and accurately, as required by the stated criteria, guideline questions and rubrics.
CHECKLIST
 Cleared your calendar for the the deadline for this application: Thursday,
December 17th at 2:45 sharp, Room N415
 Have typed every section of this application to have it accepted
 Your number only, not your name, appears on all pages of this document
 Signed and dated this cover sheet
 Have consulted Ms. Cevallos in case of any doubts about any part of the
application, at least TWO WEEKS BEFORE THE DEADLINE for submitting it
 Given 2 different on-site supervisors, from 2 different sites, the Rubrics and an
addressed envelope (Ms. M.T. Cevallos, World Languages, Needham High
School, 609 Webster Street, Needham, MA 02494-1196)
 Made on-site Supervisors aware of deadline for receipt of the Rubrics and need to
omit your name
 Have typed (double-spaced) your Personal Essay according to the Rubric
provided
DUE DATE
This application and all of its requirements must be submitted no later than Thursday, December 2 nd.
Room 415, at 2:45 p.m. sharp. At that time, we will meet to record, and verify names and assigned
numbers. The due date is non-negotiable; please make sure to clear 1 hour in your calendar in order to
ensure your presence. Thank you for your interest in the National Honor Society.
NATIONAL HONOR SOCIETY
Needham High School
Mercy T. Cevallos and Ann Perham, Co-Advisors
Student Application
Assigned Number .................
DIRECTIONS
I
IA
Please fill out accurately and TYPE the following sections.
LEADERSHIP
List the three elected or appointed leadership positions that you are most proud
of, whether held in school, community or as part of work activities. Only those positions
in which you were directly responsible for directing and/or motivating others should be
included, e.g., elected study body member, class or club officer, committee chairperson,
team captain, newspaper editor, work manager or community leader.
Junior Year
Sophomore Year
Freshman Year
Activity / Organization
Position &
Responsibilities
Hours/week, or
Hours/activity
IB
List three activities which you are most proud of and in which you have participated
during high school. Include clubs, athletic teams, musical groups and others, as well as major
accomplishments in each. Do not repeat leadership positions filled in above.
Junior Year
Sophomore Year
Freshman Year
School-related Activity
Hours/week, or
Hours/activity
Accomplishments
Leadership Rubric: School-related Activities 12.25%
Outstanding (7)
Very Good (6)
Good (5)
Student has participated in school- Student has participated in school- Student has participated in schoolrelated activities and has been
related activities and has mostly related activities but has been
able to consistently contribute, as been able to contribute, as well as inconsistent in her/his commitment
well as grow from her/his
to grow from her/his experience. and growth.
experience.
Assigned Number .................
II
COMMUNITY SERVICE
IIA
Once you have chosen the service sites, take the attached Rubrics to your on-site supervisors.
You will return it directly to us in a sealed, signed, addressed envelope, provided by you. If the person
needs/ chooses to mail it, make sure to put the correct postage on the envelope. Please impress upon
her/him the deadline for receiving the completed Rubric, as outlined on the reverse side of the form. Late
Rubrics will not be accepted, and will disqualify you from the application process. Students who
cannot extend community service beyond the requirement hours should submit both forms to 2 different
supervisors, from 2 different sites, where they have fulfilled their graduation requirements. In addition,
these students must submit evaluations from two 2 different job supervisors.
IIB
First, read the attached rubrics and, then, answer the questions accurately. Choose the service
activity to which you have committed 1/2 hours weekly, and which has felt like the best fit for you and your
interests. It should be one of the activities outside of school, in which you have participated for the
betterment of the community, i.e., a church, mosque, synagogue or temple group; also clubs sponsored
outside of school, for example, the Boy or Girl Scouts or other volunteer groups. DO NOT INCLUDE
activities such as the Boosters Christmas Tree Sales, which are required by your participation on
a team or in an internship, or any other activity performed for credit, as Community Classroom
Service. If your activity in the latter has been beyond the requirements, you may include those extra
hours.
IIB
List the Community Service experiences you have chose, and be very accurate.
Junior Year
Sophomore Year
Freshman Year
Community Service
Activity
Hours/week, or
Hours/activity
Major
Accomplishments
Assigned Number .................
III
SCHOOL AWARDS & HONORS
List all school awards, which you have earned, including those outside of school. Do not include
classroom awards. Who’s Who in America, or the Honor Roll.
Years
Junior Year
Awards / Recognition
Sophomore
Year
Freshman
Year
Years
Junior Year
OTHER Awards / Recognition
Sophomore
Year
Freshman
Year
Awards & Recognition Rubric
*CONSIDERED FOR BORDERLINE CASES ONLY.
Borderline = 00.5 - 00.9
Outstanding (7)
Very Good (6)
Good (5)
Student has earned 2 or Student has earned 1
Student has earned 1 or more
more school awards & 1 school award & 1 or more departmental awards.
or more departmental
departmental ones.
ones.
IV
PERSONAL ESSAY
Please read the attached rubric and guidelines before typing your essay on a separate sheet of
paper; the essay should be double-spaced, and carefully written, as you would any formal paper. Include
assigned number at the upper, right-hand corner.
Your essay will be evaluated using the rubric below, and it will be scored anonymously. Answer the
following questions in an essay that is:
Maximum of 2 pages
Double-Spaced
Times New Roman
Font Size 12
1” margins all around
Essay Question: What difference have you made at Needham High School? Why are you a strong
candidate for induction? Please discuss the three goals of the National Honor Society in your
essay:
1 Character
What personal qualities do you possess that you are most proud of, and how have these
qualities affected those around you?
2 Leadership
How have you shown yourself to be a leader?
3 Service
How has your work benefitted the Common Good? (Note: do not re-list your service
projects; please discuss the impact of your work.)
Scoring Rubric
Content
Character [5%]
7
Uniquely and effectively
identifies personal qualities
and their effects on others
6
Effectively identifies personal
qualities and their effects on
others
5
Does not effectively identify
specific personal qualities
and/or their effects on others
Leadership [5%]
Demonstrates exceptional
leadership experience with
detailed evidence
Demonstrates sufficient
Little evidence of leadership
leadership experience with some experience
evidence
Service [5%]
Explanation of the Common
Good shows thorough
understanding of the term;
student is clearly aware of the
connections between his/her
efforts and the effects on
others; detailed evidence
Gives a good explanation of the
Common Good but is not
thorough in making connections
between his/her efforts and
effects on him-/ herself and
others. Some evidence, some
detail
Style [5%]
Tone is engaging and there is
awareness of reader; uses the
English language creatively to
persuade the audience;
arguments developed logically
Tone is neutral; uses the English Tone is dry; use of English
language mechanically rather
language is mechanical, trite;
than creatively; arguments
arguments not well developed.
developed logically
Mechanics [5%]
No errors in spelling, grammar, Very few errors in spelling,
structure.
grammar, structure
Explanation of the Common
Good is not thorough or is
somewhat confusing. Student
does not fully understand
connections between his/her
effort and the effects on him-/
herself and others; few details
Several errors in spelling,
grammar, structure; an
unacceptable effort for an NHS
applicant
NATIONAL HONOR SOCIETY
Needham High School
Supervisor’s Assessment: Leadership Rubric (12.5%)
Student Number................
Supervisor’s Name in Full:.......................................... Contact #: ...................... ……………………
Position........................................................................................................………………………………
Name of Agency ..............................................................................................…….……………………
Nature & length of Community Service .................................................................……………………
Briefly describe student’s work with you. ........................................................…………………….
How long has student been working with you? ..........................................................….……………
The other side of this sheet is a confidential form which must be filled out by the person most
familiar with the student’s performance on-site. We have advised students to ask for a
recommendation from those with whom they have worked for 5 months or longer. Please do not
refer to the candidate by name.
All characteristics must be checked or circled to best describe the applicant; should any not apply
to the candidate, please write NA next to the corresponding description. Should any questions
arise, please contact Co-advisor, Ms. Cevallos (781 455 0800 Ex 2415) or e-mail her at
Mercy_Cevallos@needham.k12.ma.us. Descriptive paragraphs will not be taken into
consideration.
ENVELOPE: Please SEAL and TAPE the envelope and SIGN your NAME across it in the BACK to
discourage any tampering.
Thank you for your assistance.
Please Do Not Write Here.
NATIONAL HONOR SOCIETY
Needham High School
Supervisor’s Assessment: Leadership Rubric (12.5%)
Assigned Number..............
DATE FILLED OUT: .........................
CATEGORIES
Ability to Lead
Outstanding (7)
Good (6)
Competent (5)
Always Inspiring in words
and actions
Frequently inspiring in words Sometimes inspiring in
or actions
words or actions
Always sets a very good
example for others and
maintains high standards
Frequently sets a good
example for others and
maintains standards
Sets a good example for
others and maintains
standards
Always demonstrates a keen Frequently demonstrates a Sometimes demonstrates a
sense of how to encourage sense of how to encourage sense of how to encourage
others to contribute
others to contribute
others to contribute
successfully
successfully
Responsibility to the
program
Consistently acts as a liaison Frequently acts as a liaison Occasionally acts as liaison
between the director/coach between the director/coach between the director/coach
and group members
and group members
and group members
Always stays with
project until completion
and follows up where
necessary
Frequently stays with
project until completion
Does not always stay
w/project until completion
Always recognizes program
goals and maintains
momentum and commitment
towards their achievement
Frequently recognizes
program goals and
maintains momentum and
commitment towards their
achievement
Sometimes recognizes
program/project goals and
works towards improving the
program/project
Structural & Organizational Always maintains order and Frequently maintains order Sometimes maintains order
Skills
provides direction for the
and provides direction for
and usually provides
group
the group
direction for the group
Always recognizes
Frequently recognizes
Sometimes recognizes
program’s structural needs program’s structural needs program’s structural needs
and finds ways of providing
stability
Ability to Use and Share
Skills Learned
Always shows ability to learn Frequently shows ability to
and grow on-site
learn and grow on-site
Sometimes shows ability to
learn and grow on-site
Always acquires new skills & Frequently acquires new
skills & assumes some
masters them through
persistent effort
responsibility
Sometimes acquires new
skills & assumes little
responsibility
Always shares attained skills Frequently shares attained
with other members
skills with other members
Sometimes shares attained
skills with other members
NATIONAL HONOR SOCIETY
Needham High School
Supervisor’s Assessment: Community Service Rubric (12.5%)
Assigned Number............
Supervisor’s Name in Full:.......................................... Contact #: ...................... ……………………
Position........................................................................................................………………………………
Name of Agency ..............................................................................................…….……………………
Nature & length of Community Service .................................................................……………………
Briefly describe student’s work with you. ........................................................…………………….
How long has student been working with you? ..........................................................….……………
The other side of this sheet is a confidential form which must be filled out by the person most
familiar with the student’s performance on-site. We have advised students to ask for a
recommendation from those with whom they have worked for 5 months or longer. Please do not
refer to the candidate by name.
All characteristics must be checked or circled to best describe the applicant; should any not apply
to the candidate, please write NA next to the corresponding description. Should any questions
arise, please contact Co-advisor, Ms. Cevallos (781 455 0800 Ex 2415) or e-mail her at
Mercy_Cevallos@needham.k12.ma.us.
ENVELOPE: Please SEAL and TAPE the envelope and SIGN your NAME across it in the BACK to
discourage any tampering.
Thank you for your assistance.
Please Do Not Write Here.
NATIONAL HONOR SOCIETY/ Needham High School
Assigned Number..............
Supervisor’s Assessment: Community Service Rubric (12.5%)
DATE FILLED OUT: .........................
CATEGORIES
Attendance & Punctuality
Outstanding (7)
Always punctual
Good (6)
Frequently punctual
Competent (5)
Not always punctual
Always phones phones
Almost always receives
Does not always call in re.
supervisor re. attendance & good comments from direct attendance/latenesses
latenesses
supervisor re. attendance &
latenesses
Stays longer hours or comes Sometime stays longer
in extra days during the
hours
week
Misses no more than 2
assigned days of service
Work Habits
Collegiality
New Skills Learned
Does not stay longer hours
Misses 2-4 assigned days of May have missed 5-6 days
service
of assigned service
Shows initiative & leadership Able to follow directions
Follows directions w/aid from
supervisor
Always stays with
project until completion
and follows up where
necessary
Stays with project until
completion & sometimes
follows up
Does not always stay
w/project until completion
Exceeds expectations of
original goal(s)
Accomplishes original
goal(s)
Accomplishes most of the
goal(s)
Displays comfort in working Works effectively w/others
w/others
Has some difficulty working
w/others
Takes direction well
Most often takes direction
well
Does not take direction well
on occasion
Takes criticism w/ease
Takes some criticism
Does not take criticism well
at times
Always shows ability to learn Frequently shows ability to
and grow on-site
learn and grow on-site
Sometimes shows ability to
learn and grow on-site
Always acquires new skills & Frequently acquires new
masters them through
skills & assumes some
persistent effort
responsibility
Sometimes acquires new
skills & assumes little
responsibility
Always shares attained skills Frequently shares attained
with other members
skills with other members
Sometimes shares attained
skills with other members
NATIONAL HONOR SOCIETY
Needham High School
JOB Supervisor’s Assessment: Leadership Rubric (12.5%)
Student Number................
Supervisor’s Name in Full:.......................................... Contact #: ...................... ……………………
Position........................................................................................................………………………………
Name of Agency ..............................................................................................…….……………………
Nature & length of Community Service .................................................................……………………
Briefly describe student’s work with you . ........................................................…………………….
How long has student been working with you? ..........................................................….……………
The other side of this sheet is a confidential form which must be filled out by the person most
familiar with the student’s performance on-site. We have advised students to ask for a
recommendation from those with whom they have worked for 5 months or longer. Please do not
refer to the candidate by name.
All characteristics must be checked or circled to best describe the applicant; should any not apply
to the candidate, please write NA next to the corresponding description. Should any questions
arise, please contact Co-advisor, Ms. Cevallos (781 455 0800 Ex 2415) or e-mail her at
Mercy_Cevallos@needham.k12.ma.us.
ENVELOPE: Please SEAL and TAPE the envelope and SIGN your NAME across it in the BACK to
discourage any tampering.
Thank you for your assistance.
NATIONAL HONOR SOCIETY
Needham High School
JOB Supervisor’s Assessment: Leadership Rubric (12.5%)
Assigned Number..............
DATE FILLED OUT: .........................
CATEGORIES
Ability to Lead
Outstanding (7)
Good (6)
Competent (5)
Always Inspiring in words
and actions
Frequently inspiring in words Sometimes inspiring in
or actions
words or actions
Always sets a very good
example for others and
maintains high standards
Frequently sets a good
example for others and
maintains standards
Sets a good example for
others and maintains
standards
Always demonstrates a keen Frequently demonstrates a Sometimes demonstrates a
sense of how to encourage sense of how to encourage sense of how to encourage
others to contribute
others to contribute
others to contribute
successfully
successfully
Responsibility to the
program
Consistently acts as a liaison Frequently acts as a liaison Occasionally acts as liaison
between the director/coach between the director/coach between the director/coach
and group members
and group members
and group members
Always stays with
project until completion
and follows up where
necessary
Frequently stays with
project until completion
Does not always stay
w/project until completion
Always recognizes program
goals and maintains
momentum and commitment
towards their achievement
Frequently recognizes
program goals and
maintains momentum and
commitment towards their
achievement
Sometimes recognizes
program/project goals and
works towards improving the
program/project
Structural & Organizational Always maintains order and Frequently maintains order Sometimes maintains order
Skills
provides direction for the
and provides direction for
and usually provides
group
the group
direction for the group
Always recognizes
Frequently recognizes
Sometimes recognizes
program’s structural needs program’s structural needs program’s structural needs
and finds ways of providing
stability
Ability to Use and Share
Skills Learned
Always shows ability to learn Frequently shows ability to
and grow on-site
learn and grow on-site
Sometimes shows ability to
learn and grow on-site
Always acquires new skills & Frequently acquires new
skills & assumes some
masters them through
persistent effort
responsibility
Sometimes acquires new
skills & assumes little
responsibility
Always shares attained skills Frequently shares attained
with other members
skills with other members
Sometimes shares attained
skills with other members
NATIONAL HONOR SOCIETY
Needham High School
JOB Supervisor’s Assessment: Community Service Rubric (12.5%)
Assigned Number............
Supervisor’s Name in Full:.......................................... Contact #: ...................... ……………………
Position........................................................................................................………………………………
Name of Agency ..............................................................................................…….……………………
Nature & length of Community Service .................................................................……………………
Briefly describe student’s work with you.
........................................................…………………….
How long has student been working with you? ..........................................................….……………
The other side of this sheet is a confidential form which must be filled out by the person most
familiar with the student’s performance on-site. We have advised students to ask for a
recommendation from those with whom they have worked for 5 months or longer. Please do not
refer to the candidate by name.
All characteristics must be checked or circled to best describe the applicant; should any not apply
to the candidate, please write NA next to the corresponding description. Should any questions
arise, please contact Co-advisor, Ms. Cevallos (781 455 0800 Ex 2415) or e-mail her at
Mercy_Cevallos@needham.k12.ma.us.
ENVELOPE: Please SEAL and TAPE the envelope and SIGN your NAME across it in the BACK to
discourage any tampering.
Thank you for your assistance.
NATIONAL HONOR SOCIETY/ Needham High School
Assigned Number..............
JOB Supervisor’s Assessment: Community Service Rubric (12.5%)
DATE FILLED OUT: .........................
CATEGORIES
Attendance & Punctuality
Outstanding (7)
Always punctual
Good (6)
Frequently punctual
Competent (5)
Not always punctual
Always phones phones
Almost always receives
Does not always call in re.
supervisor re. attendance & good comments from direct attendance/latenesses
latenesses
supervisor re. attendance &
latenesses
Stays longer hours or comes Sometime stays longer
in extra days during the
hours
week
Misses no more than 2
assigned days of service
Work Habits
Collegiality
New Skills Learned
Does not stay longer hours
Misses 2-4 assigned days of May have missed 5-6 days
service
of assigned service
Shows initiative & leadership Able to follow directions
Follows directions w/aid from
supervisor
Always stays with
project until completion
and follows up where
necessary
Stays with project until
completion & sometimes
follows up
Does not always stay
w/project until completion
Exceeds expectations of
original goal(s)
Accomplishes original
goal(s)
Accomplishes most of the
goal(s)
Displays comfort in working Works effectively w/others
w/others
Has some difficulty working
w/others
Takes direction well
Most often takes direction
well
Does not take direction well
on occasion
Takes criticism w/ease
Takes some criticism
Does not take criticism well
at times
Always shows ability to learn Frequently shows ability to
and grow on-site
learn and grow on-site
Sometimes shows ability to
learn and grow on-site
Always acquires new skills & Frequently acquires new
masters them through
skills & assumes some
persistent effort
responsibility
Sometimes acquires new
skills & assumes little
responsibility
Always shares attained skills Frequently shares attained
with other members
skills with other members
Sometimes shares attained
skills with other members
NATIONAL HONOR SOCIETY
Needham High School
Description of Need to Work
Assigned Number............
Student’s Name in Full:..........................................
Contact #: ........................
Briefly, please describe the situation which warrants your working fifteen (15) or more hours, and
which has prevented you from doing community service or performing other activities, which are
required for those applying to the National Honor Society.