Chapter 3566

Belleville West High School

4063 Frank Scott Parkway West

Belleville, IL 62223

Candidate Information

Name_______________________________

Address_____________________________

_____________________________

City________________________________

Zip_________________________________

Your Phone__________________________

E-mail______________________________

Parent Information

Name(s)_____________________________

______________________________

Address_____________________________

_____________________________

City________________________________

Zip_________________________________

Phone_______________________________

E-mail ______________________________

Section One: Leadership

How do you feel that you demonstrate leadership in and out of school?

List any organizations that you are actively involved with (both in and out of school). Note any offices held.

3. Please list any organizations that you have been involved with since freshman year, but are currently not active in.

Section Two: Service

Explain why you feel community service is important.

List any community or school service with which you have been involved.

Explain the type of service work you would like to do with NHS.

Section Three: Character

Describe any qualities of character that make you a good candidate for National Honor Society.

2. Explain any situation you have been involved in that resulted in disciplinary action (pink slip, Saturday detention, In-school detention, suspension, tardy school, cheating, athletic ineligibility, arrests, etc.) This includes any incidents from all prior years at Belleville West.

All courses, activities, and educational opportunities are open to each student at Belleville Township High School District 201 based upon his or her qualifications and educational background without regard to race, color, national origin, gender, or disability.

Guidelines

Completion of a NHS Interest Survey does NOT guarantee membership into the National Honor Society.

All juniors and any new seniors should fill out Interest Surveys. Senior members of NHS should fill out the Senior Update instead of an Interest Survey.

Interest Surveys are due to the appropriate sponsors no later than the close of school on August 24, 2007. No late Interest Surveys will be accepted.

Do not mail the Interest Survey to the school or place it in faculty mailboxes. The Interest Survey is not officially accepted until it is signed for on the NHS log sheet.

I have read, understand, and accept the National Honor Society material and guidelines. I accept the agreements in regard to community service, deadlines, scholarship, leadership, and character. I realize that no exceptions can be made under any circumstances.

Student signature and date

Parent/Guardian signature and date

Please enclose a CHECK (made payable to BTHS West) for $30.00 with your Interest Survey. This dues fee will cover the cost membership expenses. This is a non-refundable fee, regardless if the candidate completes NHS requirements or is removed. Interest Surveys will not be accepted without checks.