Dear applicant,

Please take this form to each of your teachers and have them fill out the Grade Point and Recommendation parts of the form. Then fill out the bottom portion for your Community Involvement and have the adult supervisor from that activity sign it. You must return this form to the Renaissance Stamping table in the QUAD during lunch no later than Friday January 29th. Forms turned in after that date before the Renaissance Assembly will not be accepted.

CLASS/TEACHER	Please Circle GRADE POINT NO D or F	LIFE LONG LEARNING SKILLS CITIZENSHIP & WORK HABITS RECOMMENDATION (NO N’s or U’s or less than 2’s)
Language Arts	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
Math	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
Science	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
History	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
PE	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
Elective A*	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
Elective B*	4 3 2	NO N/U in CIT/Work Habits At least a 2 in LLL Teacher Initials:___________________________
TOTAL (To be entered at Renaissance Stamping by the PTSA Stampers)		GOLD=24-22 SILVER=21-16 BRONZE 12-15

Highest Score will be used

COMMUNITY INVOLVMENT FORM

YOUR NAME:_________________________________________________________________

NAME OF ACTIVITY:____________________________________________________________

DATES OF INVOLVMENT________________________________________________________

ADULT SUPERVISOR SIGNATURE:________________________________________________

DATE TURNED IN:____________________________________________________________