PRHS National Honor Society Student Application Packet

1|page

Palmer Ridge High School National Honor Society 2016-2017 Application Packet

Congratulations on your eligibility for consideration for membership for the Palmer Ridge High School

Chapter of the National Honor Society (NHS)! Please read carefully the detailed information below

about the NHS and the application requirements. If you choose to apply for membership consideration

for NHS, the completed application packet is due to Mrs. Cumsille in Neighborhood B no later than

3:15 on Friday, September 9th, 2016.

About National Honor Society

National Honor Society is an organization designed to develop a spirit of community among academically

motivated high school students. Members participate in activities designed to benefit their school and

community. Members are selected based on outstanding performance in the areas of scholarship, service,

leadership, and character.

Palmer Ridge High School NHS Mission Statement

The purpose of this organization is to create enthusiasm for scholarship, to stimulate a desire to render

meaningful service, to promote leadership, and to develop character among NHS members and the Palmer

Ridge High School community.

Palmer Ridge High School NHS Selection Process

Students interested in consideration for selection must submit the attached application packet, thoroughly

completed, to Mrs. Cumsille in Neighborhood B no later than 3:15 p.m., Friday, September 9th.

Once the application deadline has ended, the five-member NHS Faculty Advisory Council, appointed by

the principal, will review applications and select NHS 2015-2016 Inductees. The NHS sponsors are not

members of the Faculty Advisory Council and therefore have no selection privileges. Notification of

acceptance or rejection will be provided by mail. Those individuals accepted will be invited to an

Induction Ceremony on October 5th, 2015 at 7 p.m. Students selected for membership do not become

members of NHS until they have been inducted at the ceremony. The NHS will meet 1st and 3rd Thursdays

at 7am in the Sunset room throughout the school year. The next opportunity after Fall of 2016 for

membership will occur the following fall in 2017.

The Application Packet

Please type all portions of the application. If you are not able to type the application, use blue or black

ink and print legibly. The packet is due in its entirety, except for the four teacher recommendations which

will be turned in directly by recommending teachers to Mrs. Cumsille by the due date. At least two of the

teacher recommendations must be from a core subject teacher—English, Math, Science, Social Studies, or

World Language. The student’s section of the packet is due to Mrs. Cumsille by the due date. Since the

Leadership, Activity, and Service forms must be completed by the sponsor of the activity, applicants

should obtain sponsor statements and signatures as soon as possible.

Due Date/Questions

The completed application packet is due no later than 3:15 p.m., Friday, September 9th, 2016 to

Mrs. Cumsille in Neighborhood B. In fairness to all applicants and because of the Faculty Advisory

Council’s schedule for reviewing the applications, THIS DEADLINE IS FIRM. If you have questions, please

contact Mrs. Cumsille in Neighborhood B or by email: kcumsille@lewispalmer.org.

.

PRHS National Honor Society Student Application Packet

2|page

National Honor Society Resume

Student Portion Due to Mrs. Cumsille by 3:15 September 9th, 2016

Name: _______________________________________________________________________

Last First Middle Initial

Home Phone Number: _____________________ Email: _______________________

Please fill out the following based on high school years only.

List the classes you are taking in school year 2016-2017:

_____________________________________________________________________________

List the classes you took in school years 2014-2015 and 2015-2016:

______________________________________________________________________________

______________________________________________________________________________

List activities (clubs, teams, musical groups, etc.) in school and activities in your community in

which you have participated while a high school student. Please list the number of years you

have participated in the activity and any leadership position you have held. You must have one

documented activity and one documented position of elected, auditioned, or selected leadership

position signed by your sponsor, group leader, etc.

Activity Number of years Leadership Positions

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PRHS National Honor Society Student Application Packet

3|page

List community service activities (soup kitchen, Key Club, Boy Scouts, etc.) in which you have

participated. Please list the number of years that you have participated in each service activity.

Again, you are required to have one documented service activity signed by the sponsor of the

activity.

Service Year[s] Role

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List awards you have received (athletic awards, academic achievement, school letter, Scouts,

community recognition, etc.):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List any job experience you have:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PRHS National Honor Society Student Application Packet

4|page

Please write all of your answers within the space provided. Do not attach additional pages.

How will you manage NHS obligations with your schedule and activities?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

How will you enhance the Palmer Ridge community as a member of NHS?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please list the names of teachers who will be providing your recommendations:

______________________________ ______________________________

______________________________ ______________________________

Detach the teacher recommendation forms and sponsor documentation forms, submit to

the appropriate teachers/sponsors for completion and return to Mrs. Cumsille. Your

portion of the packet must include all of the forms EXCEPT the teacher recommendations

to be considered for membership. Ask your teachers to return their forms directly to Mrs.

Cumsille by September 9th, 2016.

PRHS National Honor Society Student Application Packet

5|page

Character Recommendation #1

To be completed by a core subject teacher (English, Math, Soc. St., Science, World Lang.)

Teacher: Return directly to Mrs. Cumsille by Friday, Sept. 9, 2016.

Student’s Name: _____________________________ Date you received this form:________

Teacher Name and Subject Taught: ______________________________________________

This form will be used to evaluate the student’s character in the NHS selection process. Thank you for

your assistance! Please rate the student in the following areas by circling the appropriate number—1 is

the lowest and 5 is the highest. Please provide comments for each score so to better enable the Faculty

Advisory Council in its selection of members.

1=Below Average 2=Average 3=Good 4=Very Good, well above average 5=Outstanding, top 5%

1. Takes criticism willingly and accepts recommendations graciously.

1 2 3 4 5

Comments: ___________________________________________________________________________

2. Consistently exemplifies desirable qualities of behavior (positive attitude, friendliness, poise,

tolerance, stability).

1 2 3 4 5

Comments: ___________________________________________________________________________

3. Upholds principles of morality and ethics.

1 2 3 4 5

Comments: ___________________________________________________________________________

4. Cooperates by complying with school regulations concerning property, behavior, dress, etc.

1 2 3 4 5

Comments: ___________________________________________________________________________

5. Demonstrates the highest standards of honesty and reliability.

1 2 3 4 5

Comments: ___________________________________________________________________________

6. Shows courtesy, concern, and respect for others.

1 2 3 4 5

Comments: ___________________________________________________________________________

7. Manifests truthfulness in acknowledging obedience to rules, avoids cheating in written work,

and shows unwillingness to profit by the mistakes of others.

1 2 3 4 5

Comments: ___________________________________________________________________________

8. Demonstrates appropriate maturity.

1 2 3 4 5

Comments: ___________________________________________________________________________

Teacher’s Signature: _________________________________________________________________

Confidential!!

PRHS National Honor Society Student Application Packet

6|page

Character Recommendation #2

To be completed by a core subject teacher (English, Math, Soc. St., Science, World Lang.)

Teacher: Return directly to Mrs. Cumsille by Friday, Sept. 9, 2016.

Student’s Name: _____________________________ Date you received this form:________

Teacher Name and Subject Taught: ______________________________________________

This form will be used to evaluate the student’s character in the NHS selection process. Thank you for

your assistance! Please rate the student in the following areas by circling the appropriate number—1 is

the lowest and 5 is the highest. Please provide comments for each score so to better enable the Faculty

Advisory Council in its selection of members.

1=Below Average 2=Average 3=Good 4=Very Good, well above average 5=Outstanding, top 5%

1. Takes criticism willingly and accepts recommendations graciously.

1 2 3 4 5

Comments: ___________________________________________________________________________

2. Consistently exemplifies desirable qualities of behavior (positive attitude, friendliness, poise,

tolerance, stability).

1 2 3 4 5

Comments: ___________________________________________________________________________

3. Upholds principles of morality and ethics.

1 2 3 4 5

Comments: ___________________________________________________________________________

4. Cooperates by complying with school regulations concerning property, behavior, dress, etc.

1 2 3 4 5

Comments: ___________________________________________________________________________

5. Demonstrates the highest standards of honesty and reliability.

1 2 3 4 5

Comments: ___________________________________________________________________________

6. Shows courtesy, concern, and respect for others.

1 2 3 4 5

Comments: ___________________________________________________________________________

7. Manifests truthfulness in acknowledging obedience to rules, avoids cheating in written work,

and shows unwillingness to profit by the mistakes of others.

1 2 3 4 5

Comments: ___________________________________________________________________________

8. Demonstrates appropriate maturity.

1 2 3 4 5

Comments: ___________________________________________________________________________

Teacher’s Signature: _________________________________________________________________

PRHS National Honor Society Student Application Packet

7|page

Character Recommendation #3

To be completed by any PRHS teacher of the applicant

Teacher: Return directly to Mrs. Cumsille by Friday, Sept. 9, 2016.

Student’s Name: _____________________________ Date you received this form:________

Teacher Name and Subject Taught: ______________________________________________

This form will be used to evaluate the student’s character in the National Honor Society

selection process. Thank you for your assistance! Please rate the student in the following areas by

circling the appropriate number—1 is the lowest and 5 is the highest. Please provide comments for each

score so to better enable the Faculty Advisory Council in its selection of members.

1=Below Average 2=Average 3=Good 4=Very Good, well above average 5=Outstanding, top 5%

1. Takes criticism willingly and accepts recommendations graciously.

1 2 3 4 5

Comments: ___________________________________________________________________________

2. Consistently exemplifies desirable qualities of behavior (positive attitude, friendliness, poise,

tolerance, stability).

1 2 3 4 5

Comments: ___________________________________________________________________________

3. Upholds principles of morality and ethics.

1 2 3 4 5

Comments: ___________________________________________________________________________

4. Cooperates by complying with school regulations concerning property, behavior, dress, etc.

1 2 3 4 5

Comments: ___________________________________________________________________________

5. Demonstrates the highest standards of honesty and reliability.

1 2 3 4 5

Comments: ___________________________________________________________________________

6. Shows courtesy, concern, and respect for others.

1 2 3 4 5

Comments: ___________________________________________________________________________

7. Manifests truthfulness in acknowledging obedience to rules, avoids cheating in written work,

and shows unwillingness to profit by the mistakes of others.

1 2 3 4 5

Comments: ___________________________________________________________________________

8. Demonstrates appropriate maturity.

1 2 3 4 5

Comments: ___________________________________________________________________________

Teacher’s Signature: _________________________________________________________________

Confidential!!

PRHS National Honor Society Student Application Packet

8|page

Character Recommendation #4

To be completed by any PRHS teacher of the applicant

Teacher: Return directly to Mrs. Cumsille by Friday, Sept. 9, 2016.

Student’s Name: _____________________________ Date you received this form:________

Teacher Name and Subject Taught: ______________________________________________

This form will be used to evaluate the student’s character in the National Honor Society

selection process. Thank you for your assistance! Please rate the student in the following areas by

circling the appropriate number—1 is the lowest and 5 is the highest. Please provide comments for each

score so to better enable the Faculty Advisory Council in its selection of members.

1=Below Average 2=Average 3=Good 4=Very Good, well above average 5=Outstanding, top 5%

1. Takes criticism willingly and accepts recommendations graciously.

1 2 3 4 5

Comments: ___________________________________________________________________________

2. Consistently exemplifies desirable qualities of behavior (positive attitude, friendliness, poise,

tolerance, stability).

1 2 3 4 5

Comments: ___________________________________________________________________________

3. Upholds principles of morality and ethics.

1 2 3 4 5

Comments: ___________________________________________________________________________

4. Cooperates by complying with school regulations concerning property, behavior, dress, etc.

1 2 3 4 5

Comments: ___________________________________________________________________________

5. Demonstrates the highest standards of honesty and reliability.

1 2 3 4 5

Comments: ___________________________________________________________________________

6. Shows courtesy, concern, and respect for others.

1 2 3 4 5

Comments: ___________________________________________________________________________

7. Manifests truthfulness in acknowledging obedience to rules, avoids cheating in written work,

and shows unwillingness to profit by the mistakes of others.

1 2 3 4 5

Comments: ___________________________________________________________________________

8. Demonstrates appropriate maturity.

1 2 3 4 5

Comments: ___________________________________________________________________________

Teacher’s Signature: _________________________________________________________________

Confidential!!

PRHS National Honor Society Student Application Packet

9|page

Co-Curricular or Community Activity Documentation

Due by 3:15 September 9, 2016.

Student: Please fill out this form completely and accurately. Next, ask the sponsor (an adult of

no family relation) of the activity to read over the document and sign, verifying the information.

If your sponsor would like to write a comment regarding your participation in the activity, he/she

may do so. This form should be returned to you and included in your application packet.

Student’s Name: __________________________ Date you received form: ____________

Name and description of co-curricular or community activity:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Sponsor’s name and relationship with students (teacher-student, coach-player, etc.):

______________________________________________________________________________

______________________________________________________________________________

Length of time of participation, in weeks: _____________________ weeks

Number of hours spent per week participating in the activity: ___________ hours per week

To the best of your knowledge, the NHS candidate named above has completed the above activity

truthfully and accurately.

Sponsor’s signature: _______________________________________________________

Sponsor’s phone number:________________________ Email:_____________________

Comments/additions:____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Sponsor: You may also contact the Palmer Ridge High School NHS Head Advisor directly

Kait Cumsille, kcumsille@lewispalmer.org, 719-867-8104.

PRHS National Honor Society Student Application Packet

10|page

Community Service Documentation

Due by 3:15 September 9, 2016

Student: Please fill out this form completely and accurately. Next, ask the community service

coordinator/someone (an adult of no family relation) receiving the community service to read

over the document and sign, verifying the information. If your sponsor would like to write a

comment regarding your participation in the activity, he/she may do so. This form should be

returned to you and included in your application packet.

Student’s Name: __________________________ Date you received form: ____________

Name and description of community service activity:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Sponsor’s name and relationship with students (teacher-student, coach-player, etc.):

______________________________________________________________________________

_________________________________________________________________________

Length of time of participation, in weeks: _____________________ weeks

Number of hours spent per week participating in the activity: ___________ hours per week

To the best of your knowledge, the NHS candidate named above has completed the above activity

truthfully and accurately.

Sponsor’s signature: _______________________________________________________

Sponsor’s phone number:_________________________ Email: ____________________

Comments/additions:____________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Sponsor: You may also contact the Palmer Ridge High School NHS Head Advisor directly

Kait Cumsille, kcumsille@lewispalmer.org, 719-867-8104.

PRHS National Honor Society Student Application Packet

11|page

Leadership Documentation

Due by 3:15 September 9, 2016

Student: List all elected or appointed leadership positions held in school, community, or work

activities; only those positions in which you were directly responsible for directing or motivating

others should be included. Examples are: elected student body representative, class or club

officer, committee chairperson, team captain, newspaper editor, work area manager or

community leader, etc. Teaching Sunday school, babysitting, and other work for which you are

paid are not considered leadership positions. Please fill out this form completely and accurately.

Next, ask the sponsor (an adult of no family relation) of the activity to read over the document

and sign, verifying the information. If your sponsor would like to write a comment regarding

your participation in the activity, he/she may do so. This form should be returned to you and

included in your application packet.

Student’s Name: __________________________ Date you received form: ____________

Name and description of leadership activity:__________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Sponsor’s name and relationship with students (teacher-student, coach-player, etc.):

______________________________________________________________________________

______________________________________________________________________________

Length of time of participation, in weeks: _____________________ weeks

Number of hours spent per week participating in the activity: ___________ hours per week

To the best of your knowledge, the NHS candidate named above has completed the above activity

truthfully and accurately.

Sponsor’s signature: _______________________________________________________

Sponsor’s phone number: _____________________ Email:_______________________

Comments/additions:____________________________________________________________

_____________________________________________________________________________

Sponsor: You may also contact the Palmer Ridge High School NHS Head Advisor directly

Kait Cumsille, kcumsille@lewispalmer.org, 719-867-8104.

PRHS National Honor Society Student Application Packet

12|page

National Honor Society

Waiver of Rights

I, the undersigned, acknowledge that by submitting this application I willingly waive any right

for myself or my legal guardian(s) to see, review or scrutinize any/all information regarding my

acceptance or rejection to Palmer Ridge High School’s chapter of the National Honor Society. If

rejected, I understand that I may petition, if I meet the standards of eligibility, to join NHS in one

year’s time.

I acknowledge this application and its contents were submitted with honesty and integrity to the

best of my knowledge and I understand that any false information stated in my application may

lead to my immediate dismissal, if accepted, to NHS.

___________________________________ ___________________________________

Student Signature Parent/Guardian Signature

___________________________

Date