BLACK SCHOLARS ACADEMY
APPLICATION
Mission
To educate, encourage, empower, and provide guidance to collegiate (25) Black men to facilitate
the procurement of future scholars, leaders & men
Eligibility
 First year Black male fulltime student or in affiliated high school program
 Must be at a fulltime Cuyahoga Community College student
 Enrolled in at least one developmental education course minimum requirement of ENG0980 and MATH-0910
 Complete Black Caucus Mentee Application
Name
S#
Address
Home Phone
Cellular Phone
Email (Personal)
Emergency
Contact
Name & Number(s)
BLACK SCHOLARS ACADEMY
Major
Current Math
Course
Current English
Course
Favorite subject(s)
Least Favorite
subject(s)
Career Goals
Are you FGC?
Yes
No
Yes
No
Are you currently
employed-where
Hobbies
Can you commit
to meeting with
your mentor twice
per month
BLACK SCHOLARS ACADEMY
Can you attend a
bi-monthly
Saturday Activity
Yes
No
Problems with
school you are
now experiencing
you would like
help with
Religious
Affiliation
In general, how
happy or adjusted
were you growing
up?
Not at all
Generally
A Little
Always
How much is your
None
Little
Somewhat
immediate family
a source of
Substantial
Very Strong
emotional support
for you?
How is your
Poor
Fair
Good
Very Good
Excellent
physical health at
present?
Would you be
willing to
Yes
No
participate in a
community
service project
Would you be
willing to use
Yes
No
TRI-C tutor twice
per month
BLACK SCHOLARS ACADEMY
PERSONAL CHARACTERISTICS
Circle any of the following words or phrases that seem to describe you as a person:
Good Health
Doing Good Work
Liking Others
Tired
Not Enough Ability
Want More Friends
Easy To Talk To
Satisfying Achievements
Leader
Lacking Energy
Doing Just Enough
Follower
Well Groomed
Good Ability
Humorous
Overweight
Cannot Concentrate
Easily Annoyed By Others
Full Of Energy
Good Work Habits
Many Friends
Illness
Should Do Better
Work Alone Too Much
Enjoying Life
Bad Habits
Want To Help Others
Fun
Good Looking
Well Liked
Popular
Studious
Shy
Mean
Unsure
Confidant
Poor
Rich
Average
Fun Person
Athletic
Lazy
Easily Distracted
Friendly
Outgoing
Attractive
Unattractive
Average Looks Articulate
Pleased With Myself
Liking Recognition
Want To Be More Important
A Good Person
Daydreamer
Want To Get Even
Liking To Look Ahead
Wanting More Attention
Confidence in Myself
Unhappy
Liking to Be In Charge
Wanting To Get Away
Religious
Atheist
Agnostic
Having Self Control
Love to Read
Intelligent
BLACK SCHOLARS ACADEMY
BLACK SCHOLARS COMMITMENT
In signing this Black Scholar Commitment I agree to abide by all the rules and
guidelines of the organization. I am also at a minimum willfully committing to do
the following:
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Participate in Academy activities
Meeting with my mentor twice per month
Attend tutoring a minimum of twice per month
Attend at least two college sponsored campus activities a semester
Maintain a 2.00 minimum GPA
Register for classes within the first week of registration
Participate in annual awards recognition ceremony
I promise to conduct myself in a manner that would be representative of an
aspiring Black Male Scholar and gentleman
Participate in community service and or service learning project
I commit to attend at least four Think Tanks a school year.
I commit to not drop out of college
I promise to inform my mentor immediately if I am having difficulty in my
classes.
Name (Print): ______________________________________________________
Signature: __________________________________________________________
Date: _________________________
BLACK SCHOLARS ACADEMY