SERVICE CLUB APPLICATION/ACTIVITY LIST
Induction into the Service Club is the highest non-academic honor at Broughton.
The Service Club recognizes and encourages service to our school through clubs, organizations, athletics and all other activities.
Juniors and seniors who are meeting Community Service requirements are eligible.
Applicants are evaluated on their service to the school only – academic information, such as GPA, is not considered, nor is community service outside school.
Full Name:______ID#: ______Grade:_____
Address:______
(Street) (City) (Zip)
CAPS Class Teacher:______Your cell #______
Your Email address:______Home Telephone:______
Father’s (Guardian’s) Full Name:______
Father’s (Guardian’s) Daytime Phone:______and Email ______
Mother’s (Guardian’s) Full Name:______
Mother’s (Guardian’s) Daytime Phone:______and Email ______
Activity List Instructions:
On the reverse side of this form, compile a list of clubs/activities in which you have been involved. The value of your service to our school will be evaluated based on the information from this list. This means that the quality of the service rendered with each activity is more important than the quantity of them. If there are any questions regarding what should or should not be included on this activity list, please see Mrs. Childrey (POD 2-6). To be considered for Service Club, you must have completed the required number of community service hours for your grade level. This form does not have to be typed but must be neat and legible. If an activity cannot be read, we cannot include it in considering your list. Please use ink as pencil does not show up well when copied. Please DO NOT fold this form or staple anything to it. Your activity list must be turned in to Mrs. Childrey in POD 2-6 no later than 2:30 pm on FRIDAY, OCTOBER 30.
In the column labeled ‘Activity’, list all of the activities you have worked with at Broughton. All activities or groups you have worked with that represent service to our school should be listed. These include all clubs, organizations, athletic teams, and performance groups. They also include being part of the Latipac, the Hi-Times, ROTC and Band even though these may be part of your class schedule. List only those activities that are recognized by our school, either as school-sponsored groups or student-created groups. Do not include activities such as FCA or Young Life, activities with your church or those with other community organizations.
In the column titled ‘Advisor’ write the name of the person who is best able to verify your participation in each activity. The Service Club may use this information to verify the level of your participation with each advisor.
In the columns labeled ‘years’ place a check mark for each year you have already participated in that activity. (Please do NOT put a check in the column for this school year (’15-’16) for activities that take place in the winter or spring. For example, if you have played a winter or spring sport for several years and plan on playing again this year, you should check the column for past years but not this year.)
If you held a leadership position within any of your activities (vice-president, team captain, committee head, etc.) indicate your position in the column labeled ‘leadership’. Otherwise, you may leave this column blank.
Please leave the column labeled ‘Code’ blank.
If you have any question as to what information should (or should not) be included on this form, see Mrs. Childrey in POD 2-6.
---Y E A R S ---
Code / Activity / Advisor/Coach / ’12-‘13 / ’13-‘14 / ’14-’15 (last year) / ’15-‘16
(this year) / Leadership Role
Please write a brief statement to describe why membership in Service Club is important to you.
______
Please do not fold this form in any way.