Home
About Us
Our Leadership
Sponsors
Programs
Welcome to Womanhood
Welcome to Manhood
Emerging Leaders
CARES
Get Involved
Welcome to Manhood Mentee Application
Mentor Application
New Membership Application
Membership Payment
Awards and Scholarships
Apply to Dr. Brown Servant Leadership Award
Media
Pictures
Videos
Newsletter
Contact Us
Home
About Us
Our Leadership
Sponsors
Programs
Welcome to Womanhood
Welcome to Manhood
Emerging Leaders
CARES
Get Involved
Welcome to Manhood Mentee Application
Mentor Application
New Membership Application
Membership Payment
Awards and Scholarships
Apply to Dr. Brown Servant Leadership Award
Media
Pictures
Videos
Newsletter
Contact Us
Donate
Volunteer
Welcome to Womanhood Application Form
Welcome to Womanhood Application Form
Step
1
of
3
33%
Date
*
MM slash DD slash YYYY
Parent/ Guardian
Name
*
First
Last
Home Phone
Cell Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Relationship to Youth/Child:
*
Mother
Father
Grandfather
Grandmother
Other
If other, please specify your relationship
Mentee's Information
Name
*
First
Last
School Information
*
Grade
School Name
Cell Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What area do you live in (Check One)
Central Los Angeles
South Central Los Angeles
Crenshaw
Florence
Watts
Athens
Inglewood
Other
If other, please specify your neighborhood:
Emergency Contact Name:
*
Relationship:
Telephone:
Short Essay Question
Why are you interested in being a part of Women of Concerned Black Men of Los Angeles’ Welcome to Womanhood Program? (Write a minimum of 200 words)
Current GPA (Grade Point Average)
Important: There is no minimum GPA requirement for this program.
Picture Activity
Please attach 3 pictures that best describe you. Once you attach the picture explain why you chose it.
Upload Photo #1
Max. file size: 100 MB.
Briefly explain why you choose photo #1 to represent you.
Upload Photo #2
Max. file size: 100 MB.
Briefly explain why you choose photo #2 to represent you.
Upload Photo #3
Max. file size: 100 MB.
Briefly explain why you choose photo #3 to represent you.
Perspective Mentee Commitment
Please check each of the following and sign where indicated:
*
I hereby acknowledge this group meets once to twice a month during the 2020 - 2021 school year.
I will do my best to attend all W.T.W workshops and leadership sessions throughout the 2020 – 2021 school year.
I will not miss more than 2 workshops throughout the 2020 - 2021 school year.
I will hold myself to high standards and push myself to be my best version.
By writing your name below, I agree to all four of the above terms and conditions.
*
Parental Consent
Please read this carefully before signing Women of Concerned Black Men of Los Angeles Mentoring Program appreciates you and your daughter's interest in her becoming a mentee. This application is intended as a means of informing and gaining the consent of the parent/guardian to allow their daughter to participate in the Women of Concerned Black Men of Los Angeles Mentoring Program. After receiving this completed application from you, we will evaluate the information and send you a letter letting you know if your daughter has been accepted into the mentoring program. Much of the information you supply in this application packet will be used to match your daughter with an appropriate mentor. Therefore, the mentoring staff may, at times, need to access and share this information with prospective mentors and other parties when it is in the best interest of the match. However, we do not reveal names until there is an initial interest from the mentee, parent/guardian, and mentor based first upon anonymous information provided about each other.
Please check each of the following and sign where indicated:
*
I give my informed consent and permission for my daughter to participate in the Concerned Black Men of Los Angeles Mentoring Program and its related activities.
I agree to have my daughter follow all mentoring program guidelines and understand that any violation on my or my daughter’s part may result in suspension and/or termination of the mentoring relationship.
I hereby acknowledge that my daughter will be transported by his/her mentor while participating in the Concerned Black Men of Los Angeles Community Mentoring Program, and that such transportation is voluntary and at his/her/our own risk.
I release the Concerned Black Men of Los Angeles Mentoring Program of all liability of injury, death, or other damages to me, my daughter, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Concerned Black Men of Los Angeles mentor, program staff, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.
I agree to allow Concerned Black Men of Los Angeles to use any photographic image of my daughter taken while participating in the mentoring program. These images may be used in promotions or other related marketing materials.
I agree to allow Concerned Black Men of Los Angeles to see my child's academic transcripts and school grades.
By writing your name below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
*
Flyer
X