100BMOR_Mentoring_Application

Dear Parents and Guardians:
Thank you for considering the 100 Black Men of Rome-Northwest Georgia Inc. as a
mentoring resource. The 100 Black Men uses the one to one and a group mentoring process with every student. The program will expose your child to many facets of personal skills development and cultural enrichment.
Please take a minute to read over the mentoring process carefully. The mentoring process is a three-way relationship between the mentee, mentor and parents. The parent is the most important part of this process. A mentor can never replace the relationship between parent and child, nor would we ever want that.
The mentoring relationship will consist of two parts, the one to one and the group mentoring. The mentor will agree to meet with your child one hour a week. This may take place in or outside of school. The mentor will contact you and inform you of the schedule that they would like to establish to spend that one hour.
In addition to one to one, your child will participate in group mentoring sessions once a month, primarily on Saturday. However, the times may change depending on the activity.
Once again, thank you for having faith in the 100 Black Men of Rome-Northwest Georgia Inc.
Sincerely,
Ron Whittington, Mentoring Chairman
Karl Gyden, President

Mentoring Enrollment Form

100 Black Men of Rome-Northwest Georgia, Inc.
Student Name:
Birth Date:

MonthDayYear
Date
Current Grade:
School:
Date Received:

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION
To be completed by the parent. Please print clearly.
Student's Home Address:
City, State, Zip Code:
Mother/Guardian Name:
Occupation:
Home Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Address:
(If different than student's)
Father/Guardian Name:
Occupation:
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Address:
(If different than student's)
Emergency Contact Name:
Emergency Daytime Telephone:
Format: (000) 000-0000.
We’d love to know more about your child’s interests, needs, or any guidance you’re hoping they receive through the program.

PROGRAM DISCLAIMER
Eligibility & Participation The 100 Black Men of Rome-Northwest Georgia mentoring program is available to male students ages 10-18 only. By submitting this enrollment form, you certify that the applicant meets these specific eligibility requirements. While we strive to support all eligible youth, participation is subject to mentor availability and program capacity.
Privacy & Electronic Communications Information that is considered sensitive should not be shared electronically. Please avoid including confidential details such as medical records, specific diagnoses, or protected student information when submitting this form. Additional information can be shared through secure channels or in-person consultations if needed.
Our Commitment At the 100 Black Men of Rome-Northwest Georgia, Inc., we believe that "What They See Is What They'll Be®." We commit ourselves to personifying the type of leaders our youth will look up to and emulate, and we embrace the immense responsibility we have to our mentees and our communities.
Learn more about our organization and mission at 100bmornwga.org.
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Mentoring Enrollment Form