Roanoke-Chowan Community College

BOSS Male Mentoring Program Student Application

Please Print in Ink Today’s Date______

Name______

Address______

City______State______Zip______Home Phone______

Social Security # or Student ID#______

Ethnicity______When did you enroll at R-CCC?______

Email Address______Cell Phone______

In case of an emergency contact: Name______

Relationship?______Phone Number______

Please answer the following questions fully and honestly. There is no right or wrong answer. The purpose of gathering this information is to have a basis for your mentoring process.

Do you have Children Yes or No How Many______

Do you have reliable transportation?______

In which classes are you performing well?______

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In which classes do you feel you need help?______

______

Do you get assistance with your homework? If yes, by whom?______

Cumulative GPA?______GPA Last Semester______

In what extracurricular activities do you participate?______

Do you currently work outside of school? Yes or No. If yes, please give employer’s name, address and phone number:______

Hours of employment:______

In what activities do you participate during your free time (music, reading, sports, art)?______

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What best describes your personality Extrovert (outgoing)______In-between______Introvert(shy)_____ My goals for participating in the Minority Male Mentoring program are: (Check all that apply) ____Develop leadership skills _____Meet faculty _____Make friends _____Learn skills _____Develop team work skills _____Develop networking skills _____Find study partners _____Build resume _____Improve career related skills _____Community service requirements _____Feel more a part of college ____Other; please specify: ______At the present time, are you confident you will graduate with your current major? ___Not confident; I am planning to change my major ____There is about a 50% chance I will change my major ____I am fairly confident I will keep my current major of study ____I am very confident that I will keep my current major of study After I finish my degree, I plan to: (Check all that apply) ___Work in the field of study _____ Not sure ____Work in the state or government setting ____Work for community organization ____Attend four year college ____Start my own company ____Enter military ___Other; please specify______

What do other people tell you that you are good at?______

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What do you think you are good at?______

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What do you like most about yourself?______

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Who do you look up to or admire?______

As a willing participant in the Mentor Program, I commit to working with my mentor through the duration of the program, attending all scheduled meetings, and communicating with program coordinator. Emergencies happen to all of us. Should I be unable to make a meeting with the group, I shall call in advance. I agree to develop personal goals and to be open to coaching and feedback. In the event that I wish to discontinue my process, I will first notify the Male Mentor Coordinator, Tremaine Kwasikpui, and discuss this before discontinuing.

______Student’s Signature Date