montclair high school
MONTCLAIR HIGH SCHOOL 100 Chestnut Street – Montclair, NJ 07042 Guidance Office Awards Program – Self Nomination Form 2016-2017 The top half of this form is to be filled out by students – Use a separate form for each service activity.
Student’s Name:
Grade:
Date:
Student’s Address:
Zip Code
Carol Schlein
Crew (Club/Activity)
Advisor’s Name (Print)
How may we contact the advisor for more information?
Advisor’s Signature
[email protected]
973-216-7100 Advisor’s Phone
Advisor’s Email
✔
I have previously received a HIGH SCHOOL service award: ⃞ Yes ⃞ No If yes, please list the years: First Year Service Pin
Second Year Bronze Pin
Third Year Silver Pin
“There are minimum service hours required for each school year” Year 1 – 10 hours (service pin)
Year 2 – 20 hours (bronze pin)
Year 3 – 30 hours (silver pin)
Year 4 – 40 hours (gold pin)
When this form is completed by the advisor, please make sure it is returned to Guidance Center by END OF APRIL, 2017
****THIS FORM WILL NOT BE ACCEPTED IF STUDENTS WRITE BELOW THIS LINE****
Please check the frequency of the activity: Other (Explain)
⃞ One-time ✔
⃞ Daily
⃞ School Activity
⃞ Weekly
⃞ Monthly
⃞ Community Activity ✔
Notice to advisor: 1.
Membership alone does not automatically entitle one to an award. Only dedicated and continuous service benefiting the school or community qualifies the student. Therefore, please make your description of service as accurate as possible.
THIS FORM WILL NOT BE CONSIDERED WITHOUT NARRATIVE
Crew team members participated in overnight Relay for Life
Please use other side if necessary …
Total number of hours served past 12 months: 12 Is this beyond the minimum number of hours required for this activity? ___Yes ___No
✔
2.
Indicate how you would rate the above student as compared to others in the same activity by circling the appropriate number. (Five indicates exceptional service.) Minimal 0 0 0
1 1 1
2 2 2
3 3 3
Exceptional 5 5 5
4 4 4
✔
✔
3.
Student’s position in organization: ⃞ President ⃞ Treasurer ⃞ Chairperson ⃞ Other:
4.
In your opinion, does this student merit an award?
Sponsor’s Signature:
⃞ ✔YES Date:
Contribution to organization Effectiveness Rapport with Others
n/a
⃞ NO
Student’s Name:
Grade:
Date:
Student’s Address:
Zip Code
Carol Schlein
Crew (Club/Activity)
Advisor’s Name (Print)
How may we contact the advisor for more information?
Advisor’s Signature
[email protected]
973-216-7100 Advisor’s Phone
Advisor’s Email
✔
I have previously received a HIGH SCHOOL service award: ⃞ Yes ⃞ No If yes, please list the years: First Year Service Pin
Second Year Bronze Pin
Third Year Silver Pin
“There are minimum service hours required for each school year” Year 1 – 10 hours (service pin)
Year 2 – 20 hours (bronze pin)
Year 3 – 30 hours (silver pin)
Year 4 – 40 hours (gold pin)
When this form is completed by the advisor, please make sure it is returned to Guidance Center by END OF APRIL, 2017
****THIS FORM WILL NOT BE ACCEPTED IF STUDENTS WRITE BELOW THIS LINE****
Please check the frequency of the activity: Other (Explain)
⃞ One-time ✔
⃞ Daily
⃞ School Activity
⃞ Weekly
⃞ Monthly
⃞ Community Activity ✔
Notice to advisor: 1.
Membership alone does not automatically entitle one to an award. Only dedicated and continuous service benefiting the school or community qualifies the student. Therefore, please make your description of service as accurate as possible.
THIS FORM WILL NOT BE CONSIDERED WITHOUT NARRATIVE
Crew team members participated in overnight Relay for Life
Please use other side if necessary …
Total number of hours served past 12 months: 12 Is this beyond the minimum number of hours required for this activity? ___Yes ___No
✔
2.
Indicate how you would rate the above student as compared to others in the same activity by circling the appropriate number. (Five indicates exceptional service.) Minimal 0 0 0
1 1 1
2 2 2
3 3 3
Exceptional 5 5 5
4 4 4
✔
✔
3.
Student’s position in organization: ⃞ President ⃞ Treasurer ⃞ Chairperson ⃞ Other:
4.
In your opinion, does this student merit an award?
Sponsor’s Signature:
⃞ ✔YES Date:
Contribution to organization Effectiveness Rapport with Others
n/a
⃞ NO
