Note: This survey is to be completed ONLY by Seniors who are returning candidates

Name ____________________________________________________________________________

Address __________________________________________________________________________

City ____________________________________________ Zip______________________________

E-mail_____________________________________

Your Phone_____________________________

Parent/Guardian(s) Name ____________________________________________________________

Phone Number _____________________________________________________________________

I. List any organizations at Belleville West that you have been involved with in your junior year. Indicate all offices that you held.

II. List any organizations outside of Belleville West that you have been involved with in your junior year. Indicate all offices that you held. Also list and describe any community service that you have done in the past year (outside NHS).

III. Explain any altercations that you have been involved in that resulted in disciplinary action (pink slip, detention, suspension, cheating, altercations with the law, probation, arrests, etc.) It is better to report anything that may be questionable rather than wait for the NHS Board to contact you.

IV. List the location and type of community service that you performed last year for NHS. If you have an idea of where you are volunteering this year, also please include this. In addition, list the grade school that you attended.

V. If you were denied candidacy or received probation your junior year from NHS, explain the circumstances. Note: Students who were removed from NHS are not eligible to re-join their senior year, unless specifically noted.

We have read all enclosed paperwork and understand all deadlines and policies (including the academic eligibility and meeting policies).

___________________________________________Student signature and date

________________________________________ Parent/guardian signature and date

Senior surveys are due to Mr. Hentze or Mrs. Quandt by August 24, 2007 along with a $30.00 check made payable to Belleville West.