John Long Middle School Chapter

John Long Middle School Chapter of the National Junior Honor Society Student Activity Information Form Directions: Please complete all sections. Type (word document can be accessed on the JLMS homepage (http://jlms.grafton.k12.wi.us/) or print all information and submit it by Friday, February 8, 2013. To be considered, the form must be completed and turned in by 3:25 on that date.

Do not be modest. Every bit of information will be used by the Faculty Council to assist with the fair consideration of your candidacy during the selection process.

As this is a student organization, students applying for selection should be the ones to complete this form.

Completion and submission of this form does not guarantee selection. Should you have questions about this form, please see Ms. Slowiak in the Library Media Center.

I. Administrative Information

Name: ______Grade: ______

Homeroom Teacher: ______

Address:

______

II. 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 were responsible for directing or motivating others should be included (e.g., elected officer for the student council or other club, team captain, or other community leader). Please include the name of the adult responsible for supervising your leadership in each position.

Dates Held Leadership Position Activity/Organization Supervising Adult III. Service Activities: List service activities in which you have participated since June 2012. These can be individual or group service projects, but should not be projects done for immediate family members, projects for which you received any sort of compensation, or projects that were required for your membership in another organization. Please ask an adult supervisor who can verify your participation in each activity to sign on the appropriate line, and also list the estimated number of hours you invested while performing this service.

Dates Activity Hours of Service Supervising Adult

IV. Other Student Activities and Accomplishments: List all other school-based activities in which you have participated in school. Include clubs, teams, musical groups, etc,. and any significant accomplishments in each.

Dates Activity Accomplishments Supervising Adult V. 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 (e.g., religious groups, clubs not sponsored by the school, Boy or Girl Scouts, community sporting or arts groups, etc.). Please include the name of the adult supervisor of each activity.

Dates Activity Accomplishments Supervising Adult

VI. Work Experience, Other Recognition and Awards, Etc.: Though not a specific criterion for membership, please list any job experiences, honors, awards, or recognition that you have received that support your candidacy for membership in NJHS.

Dates Activity Accomplishments

VII. Personal Statement Showcasing your best writing, please answer the following question:

One of the five characteristics required for membership in National Junior Honor Society is leadership. What does leadership mean to you as a young adult? How do you currently demonstrate leadership or the potential to be a good leader, both in school and in the community?

______

VIII. Signatures:

I understand that completing and submitting this form does not guarantee selection to the John Long Middle School Chapter of the National Junior Honor Society. I attest that all the information presented on the Student Activity Information Form is complete and accurate. 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: ______

______

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

Parent Signature(s): ______

______

Parent Phone Numbers: ______

______Return completed form to Ms. Slowiak in the Library Media Center by the end of the school day (3:25 p.m.) on Friday, February 8, 2013

Any questions can be directed to Ms. Slowiak (John Long Middle School NJHS Chapter advisor) at 262- 376- 5809 or [email protected] or to Mr. Kabara at 262-376-5800 or [email protected].