100 BLACK MEN OF GREATER COLUMBIA, INC.

MEMBERSHIP APPLICATION

Thank you for your interest in joining 100 Black Men of Greater Columbia, Inc. Please complete the following information. You may also submit your resume or curriculum vitae along with this application.

Date

Month

Day

Year

First name

Last name

Complete Address with City, State , and Zip Code

Phone

Marital Status

Married

Single

Spouse's Name

Professional Title

Company name & Location

Type of Business

Years of Employment/Ownership:

Briefly Describe your Professional Responsibilities:

Education: Degree(s), Institution, and Year Completed (ex: MBA, South Carolina State University, 1996)

Certifications/Special Skills/Interests:

Organizations, Affiliations (Civic or Professional)

Why do you wish to join the organization?

Are you willing to devote your time, resources and expertise to this organization in order to fulfill our goals?

Yes

The 100 Black Men of Greater Columbia helps to empower youth in our community to make positive life choices that enable them to maximize their potential. Specify the type of mentoring you enjoy the most (check all that apply).

Traditional One-on-One Programs Programs that focus on one-on-one mentoring. One-on-one mentoring requires a minimum amount of contact between the mentor and mentee. One-on-one mentoring requires a huge commitment on the part of adults to make time in their lives to cultivate the mentor-mentee relationship.

School-based These programs typically focus on working directly with students only during school hours. School based mentoring is designed to improve overall school achievement, attendance and behavior modifi cation. School-based mentoring is usually based on a group mentoring model and requires adults who have flexible schedules that will allow for visits during school hours.

Career-based Mentoring programs can provide new avenues for exploring educational and career paths. To help students make the transition from school to work, students are paired with professionals, introduced to role models, and encouraged to visit various work environments. Career-based mentoring is the key for older youth to encourage career exploration and provide them with hands-on experie

Group Mentoring Group mentoring occurs when one adult volunteer works with a small group of young people. Alt hough not a lot of research has been done on group mentoring, a large number of programs across the country are using a group mentoring model because of the challenges with recruiting African American male mentors. -David Miller,

Internet Mentoring Internet mentoring is often referred to as e-mail or e-mentoring. A growing number of programs use e-mail mentoring as a tool to develop relationships with youth. Advances in technology and the accessibility of computers have increased the number of programs using e-mail mentoring.

Have you ever been convicted of or sentenced for a violation of the law?

Yes

If yes, please provide more details of the event. (The existence of a criminal record does not constitute an auto matic bar to membership.)

I hereby confirm, represent and warrant that I have never been convicted of or charged with a vio lent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense. I hereby authorize the 100 Black Men of Greater Columbia to conduct a limited background check for the purpose of membership into the organization.

Signature

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