Any item not signed or verified by a qualified sponsor will be disregarded.

Remember to read all directions carefully!

III. SERVICE
List all service activities. This category is not for membership in clubs or on teams. Any activity in
which you have served the school community would qualify for this section. For example, helping a
teacher or tutoring fellow students, managing a team or participating in spirit activities, or working at
concession stands or selling tickets would be appropriate for this category. Include hours that go
beyond what may be required for Student Council, band, sports, and other activities. Start with the
most recent service and work backwards. If you have provided the same service for more than one year,
please complete one box and check the appropriate grade levels.

SERVICE 9 10 11 12 PURPOSE total hours

GRADE

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature

SERVICE 9 10 11 12 PURPOSE total hours

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature

SERVICE 9 10 11 12 PURPOSE total hours

Spent one afternoon after school

and helped out at mid-semester
parent teacher conferences.
Helped parents organize mini-
3. Conferences X
appointments with each teacher
and pointed other parents where
exactly to go in order to meet all
of their student’s teachers.

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature
SERVICE 9 10 11 12 PURPOSE total hours

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature
SERVICE 9 10 11 12 PURPOSE total hours

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature

SERVICE 9 10 11 12 PURPOSE total hours

6.

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature

SERVICE 9 10 11 12 PURPOSE total hours

7.

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature
SERVICE 9 10 11 12 PURPOSE total hours

8.

_______________________________________ _______________________________________
Sponsor’s name Sponsor’s signature
Attach additional pages if necessary.
 Any item not signed or verified by a qualified sponsor will be disregarded.
Remember to read all directions carefully!
IV. EXTRACURRICULAR SCHOOL ACTIVITIES
List all activities in which you have participated at school. Include clubs, teams, musical groups, etc., as
well as major accomplishments in each. Start with the most recent activity and work backwards. If you
have participated in the same activity for more than one year, please complete one box and check the
appropriate grade levels.
GRADE
ACTIVITY 9 1 1 1 PURPOSE total hours
0 1 2
1. Debate Team X X This has been one of the main
focal points of my high school
career, spanning since the
beginning of freshman year
until the end of high school
(hopefully). This is a biweekly
commitment meaning that the
moment I leave school on
Friday to Saturday evening
during a tournament weekend
is 100% devoted to debate.
Behind academics, forensics is
my number one concern
during the season.
_________________________________________ ______________________________________
Sponsor’s name Sponsor’s signature
ACTIVITY 9 1 1 1 PURPOSE total hours
0 1 2

_________________________________________ ______________________________________
Sponsor’s name Sponsor’s signature

ACTIVITY 9 1 1 1 PURPOSE total hours

0 1 2

_________________________________________ ______________________________________
Sponsor’s name Sponsor’s signature
ACTIVITY 9 1 1 1 PURPOSE total hours
0 1 2

_________________________________________ ______________________________________
Sponsor’s name Sponsor’s signature
Any item not signed or verified by a qualified sponsor will be disregarded.
V. LEADERSHIP POSITIONS
List all elected or appointed leadership positions held in school or community activities. Only those
positions in which you were directly responsible for directing or motivating others should be included:
for example, elected student body, class, or club officer; committee chairperson; team captain,
newspaper editor; or community leader. Start with the most recent leadership experience and work
backwards. If you have provided the same leadership for more than one year, please complete one box
and check the appropriate grade levels.
GRADE
Leadership Position 9 10 11 12 Activity or Purpose or Sponsor's signature
Organization Accomplishment

I was chosen to be a
chairperson for Nuevos
Amigos 2010-2011,
meaning that I will be
2. Chairperson X Nuevos Amigos
leading a fairly large
group in welcoming new
students and making club
decisions as well.

3.
 Attach additional pages if necessary

Any item not signed or verified by a qualified sponsor will be disregarded.

VI. COMMUNITY ACTIVITIES

List community activities in which you have participated and note accomplishment or purpose for each. These
should be any activities outside of school that functioned for the betterment of your community. For
example, you can include church groups, clubs sponsored outside the school, Scouts, volunteer groups, or other
community endeavors. Please note that this category cannot replace the school service that is a requirement for
membership. Start with the most recent service and work backwards. If you have provided the same service for
more than one year, please complete one box and check the appropriate grade levels.

ACTIVITY 9 10 11 12 accomplishment total Sponsor's Sponsor's Sponsor's

/ purpose hours name signature phone #
Volunteered 4
hours a week every
Sunday to gain
Hospital experience about
Volunteering X the medical
(Pharmacy) profession and to
help out the
community as
well.

REMEMBER:
• Due date: on or before 3 P.M., Friday, February 19, to Mrs. Kiser (3312).
• You have received this Student Information Form because your career GPA of 3.6 or higher
qualifies you to be eligible for membership. You must complete and submit this form on or before
the due date in order to be considered for NHS membership.
• Please read and follow all directions.
• Attach a recent photo in the space provided on page one of this form.
• Make a copy of your 1st semester report card and attach it to this form.
• Attach additional sheets if you need more space for honors, or service, extracurricular, leadership, or
community activities.
• Carefully proofread your form. You are being considered on the basis of the information that you
submit as well as what your teachers say about you on the faculty evaluation form.
• Make a copy of your completed form. The information that we require is similar to the information
that you will be asked to supply on college applications and scholarship requests. After the selection
process is completed, all forms are destroyed.
• You will be notified by mail in March to indicate whether or not you have been accepted.