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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