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HUTCHINSON HIGH SCHOOL CHAPTER

OF THE

NATIONAL HONOR SOCIETY

Student Activity Information Form

Directions:

This form is meant to be completed electronically. The only sections that should have handwritten ink are the areas requesting signatures/verification and the Adult Appraisal Form.

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. Strive to have an entry in each section. If you can’t fill all the entry spaces, no worries, if you need to add more entry spaces, feel free to do so.

Completion of this form does not guarantee selection.

Administrative Information

Patrick Walsh, HHS Principal

1200 Roberts Road

Hutchinson, MN 55350

Co-curricular Activities – List all activities in which you have participated during high school. Include clubs, teams, musical groups, etc., and major accomplishments in each.

Activity	Year	Accomplishments
9	10	11	12

Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments

Leadership Positions – List all elected or appointed leadership positions held in school, community, or work activities. Only include those positions in which you were directly responsible for directing or motivating others. (For example – you were elected to Student Council, Class Club Officer; Committee Member/Chairperson; Team Captain; Yearbook Editor; or community/civic or religious leadership positions.

Activity	Year	Accomplishments
9	10	11	12

Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments

Click here to enter your name

Service Activities – List service activities in which you have participated. These can be service projects done with a group either in or out of school, or done as individual projects performing service. Generally speaking, service activities are those which are done for or on behalf of others (not including immediate family members) for which no compensation (monetary or other) has been given. Please obtain a signature of an adult who can verify your participation in each activity.

Activity	Year	Adult Sponsor Signature Required
9	10	11	12

Click here to enter activity
Click here to enter activity
Click here to enter activity
Click here to enter activity

Other Community Activities – List other community activities in which you have participated and note any major accomplishments 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, or community art endeavors. Do not repeat participation already listed above. Please include the name of the adult supervisor of each activity.

Activity	Year	Hour/	Major	Adult Sponsor
9	10	11	12	Week	Accomplishments

Click here to enter activity	enter hours	Enter accomplishments
Click here to enter activity	enter hours	Enter accomplishments
Click here to enter activity	enter hours	Enter accomplishments
Click here to enter activity	enter hours	Enter accomplishments

Work Experience, Recognition, and Awards – List below any job experiences, honors, or recognition that you have received that support your bid to be selected for membership in the National Honor Society. Work experience may be paid or volunteer.

Activity	Year	Group or Activity / Number of hours
9	10	11	12	spent on Job or Volunteer Activity

Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments
Click here to enter activity	Click here to enter accomplishments

Click here to enter your name

AP/College classes – List below any AP/College in the Schools courses that you have taken and/or are currently scheduled to take for this school year.

Click here to enter AP/College in the Schools courses
Click here to enter AP/College in the Schools courses
Click here to enter AP/College in the Schools courses

Essay – Please answer the following essay statement. Essay must be completed using a word processor using Times New Roman font, no greater than 12 point, double-spaced with one inch margins, no less than 500 words and no greater than 750 words. Attach your essay on a separate blank sheet to the activity information packet with your name and date written on the top line.
Complete an essay describing a specific person or event that accurately describes your values. Be sure to include one of the following National Honor Society themes: leadership, scholarship, character, or service.

Adult Appraisal

Your application form must include one Adult Appraisal from a teacher that would support your candidacy. The Adult Appraisal form is enclosed. Please give the Adult Appraisal to the teacher of your choice and have her/him return it directly to Mrs. Eckhart. Please list the name of the person who is filling out your Adult Appraisal form.

Click here to enter Appraiser Name.

I understand that completing this form does not guarantee selection to NHS, and that the information presented here is accurate.

__________________________________________________	___________________________________

Student Signature	Date

I have read the information provided by my son/daughter on this form and can verify that it is true, accurate and complete in its presentation.

__________________________________________________	___________________________________

Parent Signature	Date

ADULT APPRAISAL

You must have an appraisal from an adult of your choice; preferably a teacher. Do not choose someone related to you.

Appraiser: Please complete the following:	NHS INDUCTEE NAME

N/A	Below Average	Average	Good	Excellent (Top 10%)	Outstanding (Top 2-3%)
Academic Motivation & Initiative
Academic Self-Discipline
Concerns for Others
Dependable
Emotional Maturity
Ethical and Moral Maturity
Inspires Positive Behavior in Others
Leadership – School/Community
Mentoring – School/Community
Overall Character and Personal Promise
Personal Initiative
Positive Attitude
Reactions to Criticism or Setbacks
Respect for Faculty, Peers, School, and Community Property
Respect for those unlike him/herself
Service – School/Community
Volunteer –School/Community

Check all that apply:

The main strengths of the applicant are:

□ Superiority in studies	□ Accomplishment in activities	□ Success in athletics

□ Interest in other students	□ Leadership in activities	□ Personality

□ Other_________________

The main weaknesses of the applicant are:

□ Superiority in studies	□ Conceit (too much attention to oneself)	□ Classroom attendance

□ Lack of interest in other people	□ Applicant is not well known by others	□ Classroom tardies

□ Manners and personal habits	□ Other___________________

I recommend student for National Honor Society: (attach any further recommendations if you choose)

□ Enthusiastically

□ Strongly

□ Fairly strongly

□ With reservation –(please attach sheet with reasons for reservation)

Appraiser’s Printed Name: _________________________________________ Title: ________________________

Appraiser’s Signature: ______________________________ Phone #: _________________ Date: _____________

Appraiser’s Business Address: ___________________________________________________________________

Name of Inductee: _________________________________________

Return directly to: Mrs. Eckhart – National Honor Society Advisor, 1200 Roberts Rd. SW, Hutchinson, MN 55350