National Honor Society, Shrewsbury High School Chapter

Student Activity Information Sheet

Important Background Information:
National Honor Society members are selected based on their demonstration of scholarship, leadership,
service, and character. You were invited to complete this sheet because you have a cumulative GPA of
4.00, which demonstrates scholarship. Faculty, coaches, administration, and staff have been invited to
provide feedback regarding character. This information sheet is intended to provide information
regarding activities you have completed that demonstrate service and leadership. All of this information
will be presented on an anonymous basis to the NHS Faculty Council for decisions regarding selection
to the Society. The NHS advisors (Mrs. Moynihan and Mrs. Carter) do NOT serve on this council.
Completion of this form does not guarantee selection to the SHS Chapter of the National Honor Society.

Directions: Please read thoroughly and follow directions carefully!

1. Download this sheet and fill in the information by typing directly onto the Word document and
printing it out. Do not change the format of this sheet as you fill it in.
Provide all contact information as requested and do not leave anything out! It is
important to get started on this form as soon as possible so you are not scrambling to
complete the details (such as signatures, contact information) at the last minute.
Do not be modest include all activities that pertain to each category. Keep in mind that
National Honor Society members are selected based on demonstration of ALL facets:
scholarship, leadership, service, and character so you should aim to show all of these on
your information sheet.
2. Include a letter explaining any service or leadership activities that you feel require more
information to be provided, or that you feel had the most meaning to you. Please refrain from
including your name anywhere on the letter (because it will have to be covered with white-out
anyway). It is also not necessary to sign your letter. Please limit your letter to one side of one
page, single-spaced. Letters should be formal and, as such, typed.
3. Submit hard copies of the information form and your letter to Mrs. Moynihan in A116 or Mrs.
Carter in A113 no later than Monday March 7, 2016 at 2:05 pm.
Paperwork will NOT be accepted late.
Please turn in your information form and letter at the same time in one stapled packet.
No envelopes or folders, no paperclips (please staple).
Please attach your letter to the back of your information sheet.
Please do not include this instruction sheet in your packet.
Submit your paperwork to Mrs. Moynihan or Mrs. Carter in person. Do not give it to a
friend, send it via e-mail, leave it in a mailbox, or drop it on a desk. DO NOT, under any
circumstances, interrupt a class to drop off your paperwork.

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4. If you have any questions or concerns, please e-mail Mrs. Moynihan

(memoynihan@shrewsbury.k12.ma.us) or Mrs. Carter (jcarter@shrewsbury.k12.ma.us) or stop
by in person!

I. Administrative Information
Name (First MI Last):

Jack Charles Frederick

Year of Graduation:

2017

II. Extra and Co-Curricular High School Activities

List all activities in which you have participated during your high school years (not just restricted to
SHS). Include clubs, teams, musical groups, etc. and put an X in the boxes that correspond to the
years during which you have participated. If you anticipate participation in your senior year, check
that box as well. List any specific accomplishments or learning experiences that you associate with
each activity. You may add more rows to the table if necessary.
ACTIVITY
Varsity Crew Team
Varsity Swim Team

10

11 12

ACCOMPLISHMENTS

Various Medals form the past 3 years

Qualification for states

III. Leadership Positions

Leadership is defined as a position of being in charge, guiding, or otherwise directing a group of
individuals or an organization (http://www.nhs.us).
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 your peers
(teenagers and older) should be included. For example, class or club officers, committee chairperson,
team captain, newspaper editor, work area manager or community leadership positions should be
listed below. Please include at least a contact name for each position/activity.
*If you did not hold a specific office, but your advisor/coach considers you a leader, please
provide his/her signature and e-mail address in the contact column. This information is required for
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non-elected/appointed leadership examples. You can also explain these positions in your attached
letter. You may add more rows to the table if necessary.
LEADERSHIP
POSITION

10

11

Crew Captain 2016-17

12
X

ACTIVITY,
ORGANIZTION, OR
TEAM

CONTACT NAME
(*with signature and
e-mail if necessary)

Crew team

IV. Service Activities (Not Including Course or Team Requirements)

Service is defined as any action done for or on behalf of others without any compensation (payment,
class credit, or reward) provided to the individual performing the action (http://www.nhs.us).
List community activities in which you have participated and note any accomplishments in each.
These should include any service inside or outside school in which you participated for the
betterment of your community. For example: church groups, clubs sponsored outside of school,
Boy or Girl Scouts, non-profit and volunteer groups or community/religious projects, either
completed individually or in groups. Please explain significant learning experiences from your time
spent volunteering in your attached letter.
*If it is a one-time volunteering event (i.e. a fundraising walk on a particular day), list the date of
the event in the appropriate column. If it is a recurring event (i.e. volunteering as a tutor twice a
week for 1 hour sessions over a 2 month period), write this information in the appropriate column.
SERVICE
ACTIVITY
Gymnastic Meet
Volunteer

10

Duck Dash 5k Road

Race
SHS Campus Clean
Up

11

12

*One-Time? *Recurring? List

List date
time commitment

CONTACT
Name and E-mail/Phone

X
X

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Helped friend with

his Eagle Scout
Project

One contact signature from list above: ______________________________________________

V. Work Experience, Recognition and Awards
In the space below list any job experiences, honors, or recognitions that you have received that
may help your bid for selection to NHS that you have not previously mentioned. Work
experience may be paid or volunteer.
Work, Award, or
Other Recognition
Sailing Instructor

10

11

12

Time Commitment
(if applicable)

CONTACT NAME
(*with signature and
e-mail if necessary)

40 Hours a Week Summer

1 of 4 Mass CUE 2015

Presenters

1 day

Presented to School
Committee

2 hours

Participated in
Swimming States

6 hours

US Safe Boating
Certified

2 hours

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