Minority Male Mentoring Program (3MP) Application
Thank you for interest in the 3MP. The 3MP offers unique opportunities for minority males to build
academically supportive relationships and seeks to overcome barriers to academic success. Participants
will be assigned a mentor to assist in achieving their educational goals.
Please fill out the information below.
Name: _________________________________________________________________
Date: ______________________________________
Home Address: ______________________________________________________________________________________________________
City: ______________________________________________________
Home Phone: ________________________________________
State: __________
Zip Code: __________________________
Cell Phone: ________________________________________________
Email Address: _______________________________________________________________________________________________________
Ethnicity: ________________________________________
Student ID Number: _______________________________
Educational Goal: College Transfer _____
Single _____
Married _____
Intended Major: ____________________________________________
Certificate _____
Divorced _____
Diploma _____
Children: Yes _____
No _____
Current GPA:___________________
How Many: ___________________
How many semesters have you attended Wayne Community College? _________________________________________
Hobbies/Interests/Skills: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Do you have any obligations outside of education (extra curricular activities, sports, work, church, etc.),
and if so what is the time obligation (daily, twice per week, once per week, once per month, etc.)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Emergency Contact Information:
Name __________________________________________
Relation: __________________________
Phone: ____________________
Medical Information:
Allergies: No _____ Yes _____
What are they?____________________________________________________________________
Goals for participating in the 3MP: (Check all that apply)
_____ Develop leadership skills
_____ Meet faculty
_____ Make Friends
_____ Develop networking skills
_____ Develop team work skills
_____ Build resume
_____ Find study partners
_____ Help in the community
_____ Improve career related skills
_____ Feel more a part of the college
_____ Other; please specify: __________________________________________________________________________________
At the present time, are you confident you will graduate with your current major?
_____ I am not confident; I am planning to change my major.
_____ I might change my major.
_____ I am fairly confident I will keep my current major.
_____ I am very confident I will keep my current major.
After I finish my degree, I plan to: (Check all that apply)
_____ Work in a field of study
_____ Start my own company
_____ Work in a state or government setting _____ Enter the military
_____ Work for a community organization
_____ Not sure
_____ Attend a four year college
_____ Other; please specify ___________________________________________________________________________________
As a willing participant in the 3MP, I agree to abide by all program guidelines. I commit to attending all
scheduled meetings and events of the organization as well as meeting with my mentor. If unable to attend
I will give prior notice directly to my mentor. If I wish to discontinue my relationship with my mentor, I
will first notify the 3MP Coordinator to discuss my reasons. I give permission for the 3MP coordinator
and mentors to obtain updates on my academic progression and to use photographs taken during 3MP
events.
____________________________________________________________________________
Signature
________________________________
Date