201 NE 50
th
St, Oklahoma City, OK 73105
2020-2021 TEEN SERVICE BOARD APPLICATION
First Name: ___________________ Last Name: _____________________
Age: ___ Date of Birth: _____/_____/_____ Gender: ____________
Address:_______________________________________________________________
City: ______________________________ State: ______ Zip: ____________________
Email: ________________________________________ Phone:(___)___________
High School: ___________________________________________________________
Your grade level in the fall of 2020: 9
10 11
12
PARENT/GUARDIAN INFORMATION
First Name: _________________________ Last Name:
Phone: (____)________________
Email address: __________________________________________________________
COMMITMENT OF APPLICANT
Pivot Teen Service Board members fundraise, participate in activities in the community and represent
the Pivot organization during the school year. If selected, your success in this program depends upon
your personal commitment to being an active, involved and participating member.
If accepted, there is a $20 membership fee.
Please read the following statement; think carefully about it and sign your name to indicate your
agreement:
“If chosen for the Teen Service Board, I am committed to participating in all aspects of the program,
which includes my attendance, positive attitude, respect for others and cooperation.”
______________________________________________________________________
Signature of Applicant Date
COMMITMENT OF PARENT/GUARDIAN
“If my child or dependent is selected into this program, I will guarantee my cooperation and
support with their attendance and transportation needs.”
______________________________________________________________________
Signature of Parent/Guardian Date
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201 NE 50
th
St, Oklahoma City, OK 73105
2020-2021 Teen Service Board
Essay
Please answer at least one of the questions below in essay form.
Your essay must be typed on a separate sheet, with a minimum of 100 words.
1. What three strengths do you possess that you would bring to the Teen Service Board?
In what area would you like to improve in yourself and how do you think the Teen Service
Board could help you do so?
2. Pivot’s Teen Service Board includes students who are a) established leaders, b) emerging
leaders and c) interested in learning more about leadership and growing those skills. Which
group describes you and why? How do you expect to change through membership?
3. Describe an occasion where you interacted with people different than yourself (i.e. different
culture or age). What did you learn about yourself and others from that experience?
4. Why do you want to be on the Teen Service Board? Including what you’d expect to put into
service as well as get out of the experience.
REFERENCES
(Please also include anyone you know who is affiliated with Pivot.)
Name(s) Phone Number Relationship to You
Applicant’s Signature Application Date
Applications will be accepted until June 26, 2020.
Incomplete applications will not be considered.
For consideration, please complete the application and essay and return to:
Pivot, Inc.
ATTN: Teen Service Board
201 NE 50th Street
Oklahoma City, OK 73105
Or by email: norman.markland@pivotok.org.
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