100 Black Men Mentoring Application

100 Black Men of Greater Florida GNV Mentee Application
Kasserian Ingera ("How are the children?")

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.

FIRST SESSION: Santa Fe Blount Center (Downtown Location) - 540 NW 5th, Gainesville, FL 32601 (Room: DA-006)
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Name

First NameLast Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Father/Guardian Name

First NameLast Name
Email
example@example.com
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Emergency Contact
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
School Name
Grade
List of classes you are taking this year:
What are your favorite subjects?
What subjects do you feel less sure about?
Interests
What are your hobbies and interests? How can these help you achieve success?
What extracurricular activities outside of school do you participate in: (e.g., Boy/Girl Scouts, youth programs)? (How you think these might help you achieve success?)
What is your vision for yourself when you are grown?
What do you know about how college can help you achieve success?
How do you think a mentor can help you on your journey to success in life?
How do you think you can help your mentor? (What strengths do you bring to the relationship?)

Favorites: What is your favorite

Rows	Enter your answers below
Food
Color
Person
Book
Movie
Song
Musical Group

Match Information
What days of the week are you available to participate? (Check all that apply):
What is the BEST time for you to participate? (Check all that apply):
What three words best describe you?
Saturday Leadership Academy:
Do you wish to be a part of our Saturday Leadership Academy? This program is an innovative approach to help improve social and academic performance in school. We help students develop life skills, scholastics, and enhance their learning through educational field trips. The program accepts male youth in grades 6-8.
Medical - What medical conditions currently exist that the program must be aware of? List all that apply.
All allergies (food or otherwise), behavioral issues, concentration and focus issues, other conditions
Please prepare a short essay (1 Full Page, single-spaced, typed) 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. Include your name on the essay and email it to 100blackmengnv@gmail.com

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 Florida GNV, Inc. It merely gives us a point of departure to see if we possess the resources to help you meet your goals.
100 BLACK MEN OF GREATER FLORIDA GNV, INC. MENTEE/PARENT CONTRACT

Parents must complete the following contract.
I agree to participate in the 100 Black Men of Greater Florida GNV, Inc. program. I understand that the mentor is a volunteer who wants to help me and will act as a friend, advisor, and role model. I also understand that no monetary assistance is provided by the mentor or the program.

I understand that the mentor agrees to meet with regularly, in a group setting at first and perhaps in a one to one relationship should a suitable match be found, for the duration of 1 calendar year.

In return, I agree to:
- Strive to build a positive, purposeful and powerful relationship with my mentor;
- Keep all appointments with my mentor;
- Notify my mentor (in advance) and the program coordinator if I cannot keep an appointment with him for any reason;
- Respect the guidelines set by my mentoring program;
- Attend all required program activities to the best of my ability and to give advance notice when I cannot;
- Abide by the rules and regulations of the program;
- Communicate with the program coordinator if I feel uncomfortable or experience problems at any time during the program;
- Fill out a survey at the end of the term to allow progress to be charted.
I understand that if I miss three mentoring sessions I may lose the privilege of participating in the mentoring program of the 100 Black Men of Greater Florida GNV Inc.
Parent 1 /Guardian Acknowledgement

First NameLast Name
Sign below and submit if you authorize 100 Black Men of Greater Florida GNV to mentor your child.
Parent 2/ Guardian Acknowledgement

First NameLast Name
Sign below and submit if you authorize 100 Black Men of Greater Florida GNV to mentor your child.
Should be Empty:

100 Black Men of Greater Florida GNV Mentee Application

Interests

Match Information

Saturday Leadership Academy:

100 BLACK MEN OF GREATER FLORIDA GNV, INC. MENTEE/PARENT CONTRACT