PARENTS/GUARDIANS: Please see the bottom of this form for information on the mentoring contract that must be signed.
Power is the Talents, Abilities, Skills, Knowledge and Strategies you use as leverage to control your destiny. Control over the choices of your life helps you achieve your most powerful purpose. The reason for this form is to give us information to see how we might help you along your Passage to achieving this POWER. Please be as complete, honest and thorough as you possibly can. The more we know about you, the better chance we have to match you with the right mentor.
Your Name (First, Middle Initial, Last, Suffix)
Address
City/State/Zip
Home Phone
Cell Phone
Email
Date of Birth
Gender MaleFemale
Parent/Guardian Name (First and Last)
Name (First, Middle Initial, Last, Suffix)
Relationship
Phone
Name of School Attending
Grade
List of Current Classes
Favorite Subjects
Subjects You're Unsure About
What are your hobbies and interests? How can these help you gain your true power?
What extracurricular activities outside of school do you participate in (e.g. Scouts, youth programs)? Explain how you think these might help you gain your full power.
What is your vision for yourself when you are grown?
What do you know about how college can help you achieve your power?
How do you think a mentor can help you on your passage to power?
How do you think you can help your mentor on his passage to power? What strengths do you bring to the relationship?
What is your favorite food?
What is your favorite color?
What is your favorite person?
What is your favorite book?
What is your favorite movie?
What is your favorite song?
What is your favorite musical group?
What days of the week are you available to participate? (Check all that apply) MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What is the best time of day for you to participate? (Check all that apply) MorningsAfternoonsEveningsWeekends
What three words best describe you?
Do you have any of the following medical conditions that the program should be aware of?
Allergies (food or otherwise) YesNo
If yes, please specify
Behavioral issues YesNo
Concentration and/or focus issues YesNo
Other conditions YesNo
Please prepare a short essay (1 full page, single-spaced, in your own handwriting [not typed please]) explaining what you know about 100 Black Men, what you expect out of the mentoring program and your current feelings and anticipations about participating in the program. Please make this a separate sheet and attach to this application.
Parents please do not assist in this essay, no matter the student’s age. We want to know the level of performance on this task of your protégé and will use it to determine what level of assistance we might be able to provide.
Submitting this form does not guarantee that you will be provided with a mentor from the 100 Black Men of Maryland. It merely gives us a point of departure to see if we possess the resources to help you meet your goals.
After filling out this form, please print, sign and mail in the parent/guardian contract to: Membership Director, 100 Black Men of Maryland, Inc., 4413 Liberty Heights Avenue, Gwynn Oak, Maryland, 21207-7557. Please note that you submitted a mentoring application online.
Or you may print, sign and email this application form and contract to officemanager@100bmm.org.
Please leave this field empty.
