LeadUS Mentoring Program 2015-16

Dear Prospective Mentee:

We are excited that you are considering the 2022 Mighty Men of Valor-Men of Distinction Mentorship Program in conjunction with the Daughters of Zion -WOD Mentorship Program.

The 2022 MOV-MOD program is a six (6) month program that will begin in July 2022. The program is a Transformational Wellness Mentoring Program with a focus on Body, Soul & Spiritual Development. The program is delivered in face-to-face and virtual settings. Sessions are held one Saturday and two Sundays per month – and are supported by weekly one-on-one sessions with your assigned Mentor via phone or in person. Sessions will cover, Spiritual empowerment, Man-up, financial literacy, physical and nutritional fitness, balanced lifestyles, time management, etiquette, protocol, leadership skills development, and more. More details will be provided when the application and admission process has been completed.

Personal Information
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Age *
T-shirt Size
Marital Status *

Married Engaged Single Divorced Widowed In a Relationship/Dating
How long?
ex. married 7 yrs or divorced 2 yrs
How many children? *
ex. 0 or 4
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Mobile Number *

Area Code Phone Number
Alternate Number

Area Code Phone Number
Facebook Profile
Instagram Profile
Twitter Profile
LinkedIN Profile

Education
Degree Level Earned (select all that apply)

High School Associates Degree Bachelor's Degree Master's Degree Doctorate/PhD
Fields of study
Additional Information
Training, Certifications, etc.

Attachments
Guidelines: Photos must be in a JPEG format and all videos must be under 5 minutes long.
Photo (Please submit a photo that best represents you. *
Optional - You can also submit a short video: 1. Why will you be an ideal candidate for the program? 2. What are the obstacles hindering your development?

Agreement
Thank you for your interest in the MOV-MOD Mentoring Program.

We will be contacting you to inform you of the next steps. Please sign below as a representation of your commitment to participate in the MOV-MOD Mentoring Program. By signing below you give the Coordinators of the MOV-MOD Mentoring Program permission to share this information with prospective mentors for the purpose of making meaningful, appropriate matches.
If there is any information contained within this form that you would not like us to share your with a prospective mentor, please list them here:
By signing this form, you are agreeing to the following:

• I agree to participate in an informal Interview Process before being confirmed as a mentee in this program.

• I will agree to commit to this program for the full 6 months should I be accepted into the program.

• I declare that all the information contained within this form is true and accurate.
Today's Date *

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