4413 Liberty Heights Avenue Gwynn Oak, MD 21207

Mentoring/Saturday Leadership Academy Application

Applicant Information

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.


Parent/Guardian Information

Emergency Contact (if other than parents/guardians)

Schooling Information

Your Interests

Match Information



Saturday Leadership Academy



Do you have any of the following medical conditions that the program should be aware of?






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.

Parent/Guardian Contract Information

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