Membership and Information Form Name (Print): Team: Student ID #: Counselor: CHECKLIST: Place a check for each item as it is completed. This checklist must be returned as the cover page of your completed application. Electronic applications can be found at Name & Student ID filled out Questions answered Student & Parent signature Name & Student ID filled out At least one activity in each category of, and Dates and signatures of contact persons for each activity Name & Student ID written or typed on top of essay Typed or written in ink only Name & Student ID filled out given to teachers to be filled out and returned directly to Mrs. Wolford given to an adult (non-family member) to be filled out and returned directly to Mrs. Wolford in a sealed envelope Larkspur Middle School COMPLETE APPLICATIONS ARE DUE TO THE MAIN GUIDANCE OFFICE LATER THAN 4:00PM TUESDAY, MARCH 24, 2015 1
1. Have you completed at least one full semester at Larkspur Middle School? 2. Did you receive a CUMULATIVE 3.5 grade point average or higher for the FIRST SEMESTER this school year? 3. Are you willing to attend meetings a minimum of twice a month AFTER &/or BEFORE SCHOOL? 4. Are you willing to donate at least ten service hours each semester for a total of 20 service hours during next school year? 5. Do you understand that SCHOLARSHIP (your 3.5 or above GPA) is only one of five important requirements for membership in, the other four being LEADERSHIP, SERVICE, CHARACTER, and CITIZENSHIP? 6. Are you willing to acquire one letter of recommendation from all current core subject teachers and one letter from an adult who is T a family member? Student Signature Date Parent Signature Date 2
Please list specific activities that represent the below listed qualities in you. Be specific. Include any awards that you may have received (such as Honor Roll, Perfect Attendance, Bug Roll, or Principals of American Citizenship). Some activities may be entered in more than one category. You must have AT LEAST ONE ACTIVITY FROM MIDDLE SCHOOL IN EVERY CATEGORY to be considered for membership. Attach a separate page if necessary. CATEGORIES: SCHOLARSHIP: In order to be eligible for the, you must have a minimum 3.5 GPA. LEADERSHIP: Taking the initiative to train and aid others to attain the same objective Activity Grade Level of Description Timeframe or Number of Hours of Printed Name and Signature of Adult Adviser 3
SERVICE: Volunteering time, talent, and abilities to benefit those in need in school or in the community Activity Description Grade Level of Timeframe or Number of Hours of Printed Name and Signature of Adult Adviser CHARACTER: The force within each individual which distinguishes that person from others Activity Grade Level of Description Timeframe or Number of Hours of Printed Name and Signature of Adult Adviser 4
CITIZENSHIP: The responsibilities each of us has to our home, school, or community. Activity Description Grade Level of Hours of Printed Name and Signature of Adult Adviser Please select one of the activities or organizations that you have listed in SECTION II- Completed Activities that you believe had the most significant impact on your development as an individual. In, describe how this activity exemplifies one or more of the NJHS qualities of character, scholarship, leadership, citizenship, and/or service to your school or community. This must be completed on a separate sheet of paper with your name and Student ID on the top of the page- 5
Give this form to a current core teacher to fill out and return directly to Mrs. Wolford CURRENT MATH TEACHER TUESDAY, MARCH 24 th Recommender s name: Core Subject: Math 1. Please evaluate the applicant to the best of your knowledge by checking the appropriate column. 2. Please give a brief description of the applicant s strengths. 3. Please state the applicant s weaknesses. 4. Please list any additional comments that you have regarding the applicant. 5. I would recommend this student for the (please circle one). 6
Give this form to a current core teacher to fill out and return directly to Mrs. Wolford CURRENT ENGLISH TEACHER TUESDAY, MARCH 24 th Recommender s name: Core Subject: English 1. Please evaluate the applicant to the best of your knowledge by checking the appropriate column. 2. Please give a brief description of the applicant s strengths. 3. Please state the applicant s weaknesses. 4. Please list any additional comments that you have regarding the applicant. 5. I would recommend this student for the (please circle one). 7
Give this form to a current core teacher to fill out and return directly to Mrs. Wolford CURRENT SCIENCE TEACHER TUESDAY, MARCH 24 th Recommender s name: Core Subject: Science 1. Please evaluate the applicant to the best of your knowledge by checking the appropriate column. 2. Please give a brief description of the applicant s strengths. 3. Please state the applicant s weaknesses. 4. Please list any additional comments that you have regarding the applicant. 5. I would recommend this student for the (please circle one). 8
Give this form to a current core teacher to fill out and return directly to Mrs. Wolford CURRENT SOCIAL STUDIES TEACHER TUESDAY, MARCH 24 th Recommender s name: Core Subject: Social Studies_ 1. Please evaluate the applicant to the best of your knowledge by checking the appropriate column. 2. Please give a brief description of the applicant s strengths. 3. Please state the applicant s weaknesses. 4. Please list any additional comments that you have regarding the applicant. 5. I would recommend this student for the (please circle one). 9
ANY ADULT- N FAMILY MEMBER The NJHS looks for members who reflect outstanding accomplishments in the areas of scholarship, character, leadership, service, and citizenship. TUESDAY, MARCH 24 th Give this form to an adult of your choice (non-family member) to fill out & return in a sealed envelope to Mrs. Wolford. Recommender s name: Contact Number: Relationship to Applicant: 1. How long have you known the applicant? 2. Do you have regular contact with the applicant (please circle)? 3. Please evaluate the applicant to the best of your knowledge by checking the appropriate column. 4. Please give a brief description of the applicant s strengths. 5. Please state the applicant s weaknesses. 6. Please list any additional comments that you have regarding the applicant. 10