NAME:________________________________________________________________

Please print exactly as you would like your name to appear in the induction program.

ADDRESS:_____________________________________________________________

STREET ADDRESS CITY ZIP CODE

TELEPHONE NUMBER:_________________________________________________

GRADUATION YEAR:________________

CURRENT MATH TEACHER:________________________ PERIOD:__________

You must have a cumulative GPA of 3.2 or higher at the present time. You must get verification from the counselor’s office. (Ms. Howard, Mrs. Ingram or Mr. Carroll)

Current Cumulative GPA: __________

Counselor Verification:________________________ Date:__________

Beta club is an honorary, active service organization open to sophomores and juniors with a 3.2 or higher GPA. In order to maintain membership, you will be required to attend the induction ceremony, earn a designated number of service project points (currently 15 per year), to maintain a minimum 3.2 GPA, and to uphold those qualities representative of Beta Club members. You will also be required to pay annual membership dues (currently $5 after the initial dues).

I understand the conditions of maintaining membership in the Paul G. Blazer High School chapter of the National Beta Club.

Student’s Signature: __________________________________________________

Date: _______________________________

PLEASE RETURN THIS COMPLETED FORM AND THE CURRENT MEMBERSHIP DUES OF $20 TO MRS. HACKNEY BY Wednesday, January 29, 2020. (Make checks payable to Paul Blazer High School.) YOU MUST ATTEND THE INDUCTION CEREMONY, exact date, time and location to be determined later. We are currently planning for March 11 at 4:00.