Please fill in this activity sheet with legible and neat handwriting for the Faculty

Selection Committee. This form must be completed by YOU. Word process the essay.
The essay must be completed by YOU. Due date: Turn in form to Y102 Mrs. Hansen
Del Rey by ______________________________.

Name: ________________________________________ Current Grade Level: _____

Cumulative G.P.A.: ___________

Current Courses
Semester 1 Teacher Room #

P.1 ________________________________ _
P.2_______________________________________________________________
P.3_______________________________________________________________
P.4_______________________________________________________________
P.5_______________________________________________________________
P.6_______________________________________________________________
P.7_______________________________________________________________
Semester 2 Teacher Room #

P. 1_______________________________________________________________
P. 2_______________________________________________________________
P. 3_______________________________________________________________
P. 4_______________________________________________________________
P. 5_______________________________________________________________
P. 6_______________________________________________________________
P. 7_______________________________________________________________

Other College Prep Courses Taken

Mark with a check or X

____Honors 9th English ____AP Language

____Honors 9th US History ____Honors 11th English
____Honors 9th Science/________ ____AP Literature
____Honors 10th English ____AP Stats
____Honors 10th World History ____AP Calculus
____Honors 10th Science/________ ____AP Enviro.Studies
____AP 10th World History ____AP Human Biology
____ other ____________________ ____AP Chemistry
____other _____________________ ____other _________________
____other _____________________ ____other ________________

1
 Leadership Positions You Held in the School/Community

Position Description Year Advisor’s Signature & Ph.#

1.__________________________________________________________________
2.__________________________________________________________________
3.__________________________________________________________________
4.__________________________________________________________________
5.__________________________________________________________________
6.__________________________________________________________________
7.__________________________________________________________________
8.__________________________________________________________________
Service Projects – School & Community

Type of Service/Involvement-Describe project Year/Date Advisor’s Signature & Ph. No.

1.__________________________________________________________________
2.__________________________________________________________________
3.__________________________________________________________________
4.__________________________________________________________________
5.__________________________________________________________________
6.__________________________________________________________________
7.__________________________________________________________________
8.__________________________________________________________________

Extra-curricular/Co-Curricular Activities

Describe Activity Year/Date Advisor’s Signature

1.__________________________________________________________________
2.__________________________________________________________________
3.__________________________________________________________________
4.__________________________________________________________________
5.__________________________________________________________________
6.__________________________________________________________________
7.__________________________________________________________________
8.__________________________________________________________________

2
 (Other) Community Involvement

Describe Type of involvement Year/Date Adult Leader in Charge Signature & Ph. No.

1.____________________________________________________________________
______________________________________________________________________
2.____________________________________________________________________
______________________________________________________________________
3.____________________________________________________________________
______________________________________________________________________
4.____________________________________________________________________
______________________________________________________________________
5._____________________________________________________________________
______________________________________________________________________

Essay

Attach a separate sheet of your word processed / (typed) essay

An active member of the Koolauloa Chapter possesses high standards in

leadership, scholarship, service and character. An active member attends
weekly meetings, participates in all NHS functions and activities, and upholds the
highest standards in the classroom, as well as, during non-classroom time.

Why do you think that you would make a possible candidate for the
Koolauloa Chapter of the National Honor Society? Explain how you have
demonstrated the qualities of Service, Leadership, Scholarship, and Character.
Provide examples of each.

(3 pages maximum, double-spaced typed).

You will be informed through a note on the results of the selection committee.
Thank you for taking the time to fill this form out.