405-805-6062 !
www.LiliesandReedsSociety.org
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If accepted in the G.A.P. Summer Learning Program,
you must be available to attend orientation on !
June 2, 2015 at 6:30pm at Metro Career Academy.
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! Lilies & Reeds Society summer program G.A.P. stands to provide students with the tools to become better
leaders in our community. The Society works with schools, companies, community organizations, healthcare
professionals and families to transform the conditions and systems that lead will to healthier children. Our
vision is that young people will be encouraged through the G.A.P. Summer Learning Program. That they
will begin to take an active role in their own lives to overcome barriers keeping them from a
healthy and successful path in life. The six week summer program is an extension of
Lilies & Reeds Society life skills classes taught at Metro Career Academy focusing on
key components and experiences students typically lack to prepare for adulthood.
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AS A G.A.P. SUMMER LEARNER, YOU’LL GET TO:
• Learn about:
• Spend two nights & three
• Time, Anger & Stress Management
days (Tuesday, June 23rd• Healthy Relationships & Wellness
Thursday, June 25th) at
• Financial Preparation & Goal
Elephant Rock Nature Park
Setting
(Tahlequah, OK) to
• Independent Living Skills
experience river rafting,
• Cooking Instruction
camping, hiking, games and
• Nourishing Snacks & Lunches
learning more about how you
• *Earn $375 for program completion
can become an upstanding
• Attend an awards banquet to honor
member of your community.
you
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9:00AM-11:30AM
TUESDAY, JUNE 9TH THURSDAY, JULY 23RD
!• June 9th & 11th
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June 16th & 18th
June 23rd - 25th
July 7th & 9th
July 14th & 16th
July 21st & 23rd
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! Application Checklist
Apply
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! 1. Carefully fill out all sections of the application accurately. We cannot Today
! consider incomplete forms.
! 2. The application and two recommendation forms must be ! completed and received by Friday, May 22, 2015. Incomplete or late !! applications will not be considered.
3. Make sure to allow enough time to give your two recommenders the recommendation
form to review and for them to submit the forms before the deadline.
*In order to receive the $375 stipend, each student must meet the following requirements:
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• Attend all 12 sessions, including camping/rafting
trip and awards banquet
• Must entering the 2015-2016 school year as a
sophomore, junior or senior
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• Reside in the Oklahoma City Public
School District
• Be a full participant in each session
2015 G.A.P. Summer Learning Program Application
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Application! !
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DATE
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Please fill in all information accurately and honestly before submitting the application.!
We appreciate your thoughtful, considered and candid comments.!
STUDENT INFO.
NAME
First
Last
BIRTHDATE
PHONE
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Indicate Preference
Middle
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GENDER
O Home
(
Jr., Etc.
O Male
O Female
O Cell
)
(
GRADE
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EMAIL
HOME ADDRESS
Street
City
State
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PARENT / GUARDIAN 1
PARENT / GUARDIAN 2
NAME
NAME
ADDRESS
ADDRESS
WORK
WORK
CELL
CELL
EMAIL
EMAIL
EMPLOYER
EMPLOYER
OCCUPATION
OCCUPATION
EDUCATION / DEGRESS
EDUCATION / DEGRESS
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
Zip
2015 G.A.P. Summer Learning Program Application
FAMILY Continued
LIVES WITH!
O Both Parents
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O
Parent 1
O
O Female / Male Guardian
Parent 2
O
Step-father
O
Step-mother
CHECK APPLICABLE!
O
Parents Divorced
O
Parents Separated
O
Parent 1 Deceased
O
Parent 2 Deceased!
MATERIALS SHOULD BE MAILED TO!
O Both Parents O Parent 1 / Guardian O Parent 2/Guardian
ETHNICITY Optional!
O African American O
O Other, please specify:
Native American
O
O Other
O Asian/Pacific Islander
O Prefer not to answer
Hispanic/Latino
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O
Caucasian
O
Multiracial !
SIBLINGS
NAME
BIRTHDATE
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SCHOOL
NAME
BIRTHDATE
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SCHOOL
NAME
BIRTHDATE
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SCHOOL
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GRANDPARENT 1
GRANDPARENT 2
NAME
NAME
ADDRESS
ADDRESS
PHONE
PHONE
EMAIL
EMAIL
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Signature
PARENT / GUARDIAN
DATE
*G.A.P. Summer Learning Program admits students of any race, religion, color, or national or ethnic origin and does not
discriminate on the basis of sex, race, color, or national or ethnic origin.
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
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2015 G.A.P. Summer Learning Program Application
COUNSELOR/TEACHER RECOMMENDATION
The student named above has applied to G.A.P. Summer Learning Program. Your honest evaluation of the applicant will be helpful
to the Admissions Committee. Please complete this form and send the original to G.A.P. Summer Program at P.O. Box 1736,
Bethany, OK 73008. You may keep a copy for your own records. Your comments will be held in the strictest confidence. Thank you
very much for your assistance.
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STUDENT INFO.
HOW LONG HAVE YOU KNOW THE CANDIDATE AND IN WHAT RELATIONSHIP?!
Please list subjects taught, including level of difficulty and grades earned by the applicant, if applicable!
WHAT ARE THE FIRST WORDS THAT COME TO MIND WHEN DESCRIBING THE APPLICANT?
WHAT ARE THE FIRST WORDS THAT COME TO MIND WHEN DESCRIBING THE APPLICANT?
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PERSONAL QUALITIES
Weak
Fair
Good
Excellent
Exceptional
Personal Conduct/Integrity
Creativity
Reaction to suggestion / Criticism
Ability to relate to peers
Ability to relate with adults
Sense of humor
Work ethic
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WHAT ARE THE PERSONAL STRENGTHS AND WEAKNESSES OF THIS CANDIDATE? CONSIDER SUCH!
CATEGORIES AS CHARACTER, HONESTY, MATURITY, RESPONSIBILITY, LEADERSHIP, SENSE OF !
HUMOR, SOCIAL SKILLS, AND CONCERN FOR OTHERS.
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
2015 G.A.P. Summer Learning Program Application
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ANY OTHER COMMENTS OR INFORMATION YOU BELIEVE MIGHT BE HELPFUL?
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TEACHER / SCHOOL INFO.
School Name
School Address Street
City
State
Zip
Phone
Available to Discuss
Name Please Print
Email
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Signature
Teacher
DATE
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
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2015 G.A.P. Summer Learning Program Application
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COUNSELOR/TEACHER RECOMMENDATION
The student named above has applied to G.A.P. Summer Learning Program. Your honest evaluation of the applicant will be helpful
to the Admissions Committee. Please complete this form and send the original to G.A.P. Summer Program at P.O. Box 1736,
Bethany, OK 73008. You may keep a copy for your own records. Your comments will be held in the strictest confidence. Thank you
very much for your assistance.
!
STUDENT INFO.
HOW LONG HAVE YOU KNOW THE CANDIDATE AND IN WHAT RELATIONSHIP?!
Please list subjects taught, including level of difficulty and grades earned by the applicant, if applicable!
WHAT ARE THE FIRST WORDS THAT COME TO MIND WHEN DESCRIBING THE APPLICANT?
WHAT ARE THE FIRST WORDS THAT COME TO MIND WHEN DESCRIBING THE APPLICANT?
PERSONAL QUALITIES
Weak
Fair
Good
Excellent
Exceptional
Personal Conduct/Integrity
Creativity
Reaction to suggestion / Criticism
Ability to relate to peers
Ability to relate with adults
Sense of humor
Work ethic
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WHAT ARE THE PERSONAL STRENGTHS AND WEAKNESSES OF THIS CANDIDATE? CONSIDER SUCH!
CATEGORIES AS CHARACTER, HONESTY, MATURITY, RESPONSIBILITY, LEADERSHIP, SENSE OF !
HUMOR, SOCIAL SKILLS, AND CONCERN FOR OTHERS.
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
2015 G.A.P. Summer Learning Program Application
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ANY OTHER COMMENTS OR INFORMATION YOU BELIEVE MIGHT BE HELPFUL?
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TEACHER / SCHOOL INFO.
School Name
School Address Street
City
State
Zip
Phone
Available to Discuss
Name Please Print
Email
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Signature
Teacher
DATE
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
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2015 G.A.P. Summer Learning Program Application
STUDENT SECTION
The teachers and admissions committee at G.A.P. Summer Learning Program would like you to have an opportunity to tell us about
yourself. Please take the time to think about your answer to each question and respond in a well-organized paragraph. Please
respond in your own handwriting. You may use additional paper but not your computer. It should be your own work and should
reflect your feelings and ideas.
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STUDENT NAME
1. Describe a person you respect and tell what it is you respect about this person.
2. Of what activities and/or accomplishments are you most proud?
3. Why do you think G.A.P. Summer Learning Program might be a good fit for you?
4. Are you a pregnant or parenting teen? If so, please list your due date or name(s) & age(s) of your son or daughter.
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
2015 G.A.P. Summer Learning Program Application
5. What academic subjects interest you the most? Why?
6. What is your favorite thing to do outside of school?
7. What is the bravest thing you have ever done?
8. What else would you like us to know about you?
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Signature
Student Signature
DATE
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405-805-6062 | www.LiliesandReedsSociety.org | P.O. Box 1736 | Bethany, OK | 73008
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