<p> Roanoke-Chowan Community College</p><p>BOSS Male Mentoring Program Student Application</p><p>Please Print in Ink Today’s Date______</p><p>Name______</p><p>Address______</p><p>City______State______Zip______Home Phone______</p><p>Social Security # or Student ID#______</p><p>Ethnicity______When did you enroll at R-CCC?______</p><p>Email Address______Cell Phone______</p><p>In case of an emergency contact: Name______</p><p>Relationship?______Phone Number______</p><p>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.</p><p>Do you have Children Yes or No How Many______</p><p>Do you have reliable transportation?______</p><p>In which classes are you performing well?______</p><p>______</p><p>In which classes do you feel you need help?______</p><p>______</p><p>Do you get assistance with your homework? If yes, by whom?______</p><p>Cumulative GPA?______GPA Last Semester______</p><p>In what extracurricular activities do you participate?______</p><p>Do you currently work outside of school? Yes or No. If yes, please give employer’s name, address and phone number:______</p><p>Hours of employment:______</p><p>In what activities do you participate during your free time (music, reading, sports, art)?______</p><p>______</p><p>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______</p><p>What do other people tell you that you are good at?______</p><p>______</p><p>What do you think you are good at?______</p><p>______</p><p>What do you like most about yourself?______</p><p>______</p><p>Who do you look up to or admire?______</p><p>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.</p><p>______Student’s Signature Date</p>