BBRB

* First Name

* Last Name

Address

City

State

Zipcode

* Telephone

* Email

Text Messaging?
Yes No

How were you referred to becomming a mentor?

Self - i.e saw flier or poster

Someone gave me a card to sign up

I saw ad on IG

Friend referred me

Program Staff invited me to sign up

Other - explain

Please explain the answer for other

Date of Birth

Ethnicity

Best time to contact

From: : To: :

Are you over the age of 21?
Yes No

Are you able to commit to 1 hour a day meeting with a mentee online?
Yes No Maybe

Are you able to provide your availability weekly if your schedule needs to change from week to week?
Yes No

Are you willing to attend a 1 hour orientation to obtain program mentor standard practices?
Yes No

If you are a are you a father? (check all that apply)
My children are younger than 10 My child(ren) are older than 10 My child(ren) are adults

Did you graduate from H.S.or receive your GED?
Yes No

Select level of education that applies to you. (check all that apply)
Bachelor's Degree Master's Degree Trade

What was your major or trade?

Did you grow up with your father in the home?
Yes No

Did you father help raise you (in or outside of the home?
Inside the home Outside the home

Did you have male role model growing up?
Yes No

Have you ever had a mentor?
Yes No

Do you think it is important for Black boys to have a mentor?
Yes No

Did you struggle with reading as a child?
Yes No

Will you be comfortable listening to a mentee read out loud with you for 15 mins or more?
Yes No

Are you ok interacting with mentees parents occasionally?
Yes No

What is your ideal vision of a mentor and mentee relationship? (Please explain)

What are 1-3 of your current hobbies?

What was the last concert you attended?

What was the last community event you attended?

Do you believe that therapy can be helpful for some if not all?
Yes No

Would you be interested in group therapy (therapy with other Black mens) if your insurance covered it?
Yes No

What issues do you believe affect the Black boys the most? (please let any topics that come to mind i.e. Criminal Justice, Restorative Justice, Self Advocacy, Continual Education, Family Systems)

If you were asked to present a lecture on any topic that you were comfortable with, what would it be?

If there was an opportunity for face-to-face mentoring that suited your schedule would you be interested?
Yes No Maybe

Mentor Form (* Required fields)