Next Level Men Mentoring Program Application
Please complete this form for consideration of admission to this program. Submission of your application does not guarantee attendance. Selected applicants will be notified once enrollment is confirmed.
I acknowledge that I have read and understand the program details.
*
Yes
Full Name
*
Last Name
First Name, Middle Initial
Participant's Age
*
Please Select
14
15
16
17
18
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name of School Participant Attends
*
Grade Level
*
Please Select
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Post HS Graduate
T-Shirt Size
*
Please Select
S
M
L
XL
2XL
3XL
4XL
Parent/Guardian's Name
*
Last Name
First Name
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian's Email Address
*
example@example.com
Please rate the following for your participant
*
Rows
Excellent
Good
Average
Fair
Needs Improvement
Behavior
Communication with Adults
Study Habits/Grades
Types of Peer Influence Around Him
Please give more details for your answers above.
*
Please let us know if your participant engages in any of the following behaviors.
*
Rows
Uses Regularly
Uses Moderately
Does Not Use/Does Not Apply
Drugs (including Marijuana or Other Recreational Drugs)
Alcohol
Cigarettes, Cigars and/or Vaping
Please give more details for your answers above.
*
Do you commit to attending and participating in ALL sessions?
Yes
No
Student Acknowledgement: By signing below, we acknowledge that we understand the program expectations, attendance requirements, transportation responsibility, and stipend guidelines.
Signature
*
Parent Acknowledgement: By signing below, we acknowledge that we understand the program expectations, attendance requirements, transportation responsibility, and stipend guidelines.
Signature
*
How did you hear about the program?
Please Select
Social Media
School or University
Friend or Colleague
Online Search
Other
Please rate our work in your community
1
2
3
4
5
Save & Continue Later
Submit Application
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