DVSS Grade 12 Self-nomination Form Name: ______________________________

ACTIVITY RECORD - Please list, in order of importance to you, up to three school or community activities in which you have invested significant energy in the last three years, and state what you contributed. Be sure to include approximate hours per week and the start and end dates (MM-YYYY) for each activity.

Activity / Role Hrs/Wk

Start Date (MM-YYYY)

End Date (MM-YYYY)

Who or what prompted your involvement?

Describe your contribution

Activity / Role Hrs/Wk

Start Date (MM-YYYY)

End Date (MM-YYYY)

Who or what prompted your involvement?

Describe your contribution

Activity / Role Hrs/Wk

Start Date (MM-YYYY)

End Date (MM-YYYY)

Who or what prompted your involvement?

Describe your contribution

Please list activities in which you have participated since September , including those in this academic year. Where applicable, please indicate your role in each year you participated.

SCHOOL AND COMMUNITY SERVICE: e.g. Yearbook – video editor, Haven – participant 2012- 2013- 2014-

2013 2014 2015

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ARTISTIC/MUSICAL: Put “S” for school activites, “P” for Private lessons, “C” for community activities, and “I” for independent pursuits. Add “SL” if you were a section leader or “CM” for concert/choir master.

2012- 2013- 2014- 2013 2014 2015

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COMPETITIONS/CONFERENCES:/SPECIAL PROGRAMS:

2012- 2013- 2014- 2013 2014 2015

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ATHLETICS: Put “S” for school teams, “HL” for house-leagues or intramurals, or “T” for club community sports. NOTE: If you were captain of a team, put “C”. 2012- 2013- 2014-

2013 2014 2015

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INTERESTS / PERSONAL PURSUITS: AWARDS / DISTINCTIONS:

EMPLOYMENT / ENTREPRENEURIAL – Please list your current and previous employment (if applicable): Employer Position From (MM-YYYY) To (MM-YYYY) Avg. Hours/week

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Will you be eligible for, and reliant on, OSAP to pay for your education? If yes, please check