MIDDLETOWN HIGH SCHOOL NORTH National Honor Society Martha Pennington Chapter Student Activity Information Form Directions: Please complete all sections. Do not be modest. Every bit of information can be used by the Faculty Council to assist with the selection process. Completion of this form does not guarantee selection. Signatures for each activity must be obtained to verify your participation. Be sure to delete the examples prior to submission!!! I. School Sponsored Activities: List all activities in which you participated during high school. Activity Year Accomplishments (if a leadership position please indicate here and elaborate below) 9 10 11 12 Coach/Advisor Baseball X X X X Highest Average, 20 Steals, Co-Captain Mr. B Jefferson
II. Leadership Positions: List all elected or appointed leadership positions held in school, community or work activities. Positions in which you were responsible for directing or motivating others should be included. For example: elected student body; class or club officer; committee chairperson; team captain; newspaper editor; work area manager; or community leader. Leadership Year Explanation Position 9 10 11 12 Coach/Advisor Spanish Honor Society X President Mrs. J Doe III. Community Service/ Volunteerism: List community activities in which you have participated and note any major accomplishment in each. These should be any activities outside of school in which you participated for the betterment of your community. For example: Church groups, clubs sponsored outside the school, Boy or Girl Scouts, volunteer groups, or community art endeavors. Activity Year Total Explanation 9 10 11 12 No. Hrs. Supervisor Worked Habitat for X X X 20+9+10 Helped Build Houses for Poor Mr. T Smith Humanity =39 Families
IV. Recognitions and Awards: List below any, honors or recognitions that you have received which support your bid to be selected for membership in the National Honor Society. Recognition or Award Kiwanis Honor Athlete Year/ Grade Explanation Coach/ Advisor 2007 / 11 th grade Plaque & certificate awarded for the Highest GPA for a student on a team Ms. Marie Adams V. Work Experience: List below any work experience you have. This may be paid or unpaid. Job/ Location Year Duties Supervisor Cashier/ Pathmark 7/2007-9/2008 Ring up customers orders, restock shelves, and price check Mr. Mark Peters VI. Required Personal Statement: It is important that candidates devote their attention to the personal statement. Type an essay (150-250 words), which highlights important experiences and achievements in your high school years. As you write, keep in mind the four cornerstones of the National Honor Society: character, leadership, scholarship and community service. ****************************************************************************** ********************************
Please read the following statement carefully and sign: I understand that the completion of this form in no way guarantees my membership in The National Honor Society, but that I am being considered and reviewed for membership in accordance with the rules and regulations of The National Honor Society and the local chapter s bylaws. I have attended the mandatory information meeting andunderstand all instructions. I will accept the decision of the Faculty Council charged with the responsibility of selecting new members as final. I wish to be considered for membership. I do not wish to be considered for membership at this time. Student Name (Printed) Student Signature Date Parent Signature Date
MIDDLETOWN HIGH SCHOOL NORTH National Honor Society Martha Pennington Chapter Community / School Service Record Form Date: Student Name: Name of Organization: Description of Services: Number of Hours This Month: Total Hours Accumulated To Date: Supervisor s Name: Supervisor s Title: Supervisor s Phone # ( ) _- _(If not a H.S. NORTH faculty member) Supervisor s Signature: Submit this form to Mrs. Diercksen in 2127