For office Use Only:
#__________
Student Activity Information Form
Avon Grove Chapter
of the
National Honor Society
Directions: Please complete all sections. Applicant must type or print all information and submit it by
the published deadline. Do not be modest. Every bit of information will be used by the Faculty Selection
Committee to assist with the fair consideration of your candidacy during the selection process. Include
the name, phone number and signature of the adult responsible for supervising you in each position or
activity (It may not be your own parent’s signature). Without this information, that activity/position
will not be considered in your selection. Attach another sheet of paper if additional space or
explanation is needed. If you have questions about this form, please contact Mrs. Weyman in room 306
or Mr. Habbart in room 317.
All forms are due no later than Friday, September 22, 2017 at 3:00 p.m.
I.
Administrative Information
Last Name: _____________________________ First Name: ___________________________
Current grade level:_______________
First Period Room #/Teacher_____________________________________________________
Did you attend the NHS Informational Assembly on May 24, 2017? (circle one)
II.
YES
NO
Signatures:
I attest that the information I have supplied here is complete and accurate. I understand that completing
and submitting this form does not guarantee selection to the Honor Society. If selected, I agree to abide by
the standards and guidelines of the chapter and to fulfill all of my membership obligations to the best of
my ability.
___________________________________________________________________________________
Student Signature
Date
I/we have reviewed the full Student Information Form completed by my son/daughter and can verify that
it is true, accurate, and complete.
___________________________________________________________________________________
Parent Signature(s)
Date
For office Use Only:
#__________
III. Leadership Positions – List all elected or appointed leadership positions or other positions of
responsibility held in school, community, or work activities. Only those positions in which you are/were
responsible for directing or motivating others should be included. Include all past, present and future
positions. Please attach an explanation for any positions not listed below and/or gaps in postions. If you
are currently a junior, you need a minimum of 1 leadership position since 9th grade. If you are
currently a senior, you need a minimum of 2 leadership positions since 9th grade.
What is and is not leadership
(This is not an all inclusive list)
Is leadership:
Is NOT leadership:
band/orchestra section leader/concert master
band/orchestra first chair/leader
drum major
accompanist for choir
Boy Scout and Girl Scout leadership position
manager of high school sports team
Work on your own Eagle scout/Gold award project
assistant captain
cub scout den chief
teaching assistant/student teacher
senior patrol leader
assistant patrol leader
instructor/coach of a sport outside of school
other Boy Scout & Girl Scout positions
Team captain
committee member of a club
Assistant coach
bible study & bible camp assistant/helper/aide
Referee
acolyte
camp counselor
play in church band/choir
Student Forum member
yearbook position
Officer of a club/class/student council
student council class representative/committee member
Committee chair of a club
school board representative
Newspaper Editor
Student ambassador
FCA leader/FCA team leader
People-To-People leadership summit
Bible school/bible study teacher
tutoring/giving lessons/babysitting
Stage manager/director
head dishwasher
babysitter
Host
Book Club member/leader
Leadership Position
Activity/Organization
Year
9
10
11
12
Supervising Adult’s
Name,
Phone # and Signature
IV. Service Activities – List service activities in which you have participated. These can be individual or
group service projects done either in or out of school. Generally, service activities are those that are done
for or on behalf of others (not including immediate family members) for which no compensation
(monetary or otherwise) has been given. Please attach an explanation for any activities not listed below
and/or gaps in service. If you are applying during your junior year, you need a minimum of 20 hours,
the majority of these hours need to have been completed within the last year. If you are applying
during your senior year, you need a minimum of 30 hours, the majority of these hours need to have
been completed within the two last years. (Do not repeat leadership positions)
What is and is not community service
Is community service
Santa Breakfast for band
volunteer at church event
teaching bible school
working at Ronald McDonald House
Boy Scout and Girl Scout volunteer projects
Work at The Bridge in West Grove
Volunteer at the YMCA
Road clean-up
Volunteer as a camp counselor
Childcare @ PLE/AGI during parent conferences
Volunteer @Jennersville Hospital
Volunteer @ Jenners Pond
Library volunteer
Volunteer instructor/coach
Habitat for Humanity
Volunteer Referee
CYFF Aide
Participate in 30 Hours of Famine
Helping out at the West Grove Garage
Activity
(This is not an all inclusive list)
Is NOT community service
blood drive volunteer during school hours
volunteer at PSAT night
volunteer around the high school
concert/performance in the community
school fundraisers
coffee house
accompanist for choir
manager of high school sports team
help with open house at AGHS
after school tutoring
Tri-M functions/events
indoor color guard show
any school events
spaghetti dinner
assisting/helping/working at parent's work
yard sale
pit and/or pep band
playing in church band
Blood donor
Total
Hours of
Service
Date(s) of
Service
(approx. M/YY)
Supervising Adult’s Name,
Phone # and Signature
V. Other Student Activities – List all other school or non-school activities in which you have
participated. Include clubs, teams, jobs, musical groups, etc., and any significant accomplishments in
each. Do not repeat participation already listed above.
Activity
Accomplishments
9
Year
10 11
12
Supervising Adult’s Name,
Phone # and Signature
VI. 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 (e. g., religious youth groups, clubs sponsored outside
the school, Boy or Girl Scouts, community art endeavors, etc.). Do not repeat participation already listed
above.
Activity
Accomplishments
9
Year
10 11 12
Supervising Adult’s Name,
Phone # and Signature
VI. On the back of this page, in your own handwriting and in 36 words or less, tell us something
about yourself that exemplifies and qualifies you for membership not already shared in your application.