100 BMA Membership Application

100 BLACK MEN OF AUGUSTA, INC

Membership Application Form
The 100 Black Men of Augusta, Inc. seeks to serve as a beacon of leadership by utilizing our diverse talents to create environments where our children are motivated to achieve, and to empower our people to become self-sufficient shareholders in the economic and social fabric of the communities we serve.
Name

PrefixFirst NameLast Name
Birth Date

MonthDayYear
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Educational Background
Occupation
Please explain how you can enhance our organization
What is your area of interest or expertise that you would like to share with our mentees?
Do you have at least 3 hours per week to dedicate to mentoring?

YesNo
Are you available at least one Saturday morning per month for our Saturday Academy sessions?

YesNo
What Age Group are you interested in mentoring?

ElementaryMiddle SchoolHigh SchoolCollegiate
Do you have any volunteering experience? If yes, please describe.
Date

MonthDayYear
Date
Signature
Application Fee

There is a $45 Application fee required. You can pay this fee by visiting https://100blackmenofaugusta.org/donations

100 BLACK MEN OF AUGUSTA, INC