PRIDE of Halifax Community College
Male Mentoring Program Application
Date ________________ Semester: Spring □ Summer □ Fall □
Name_______________________________________________________________________
(Last) (First) (MI)
Last 4 digits of your social security number: __________ HCC ID number: ___________________
Birth Date: ___________ Age: ________
Check the ethnic group with which you most identify:
___ American Indian/Alaskan Native ___ Asian ___ Black/African American ___ White
___ Hispanic/Latino ___ Native Hawaiian/other Pacific Islander
Mailing Address ________________________________________ City _________________ Zip Code ____________
Home Phone _______________ Work Phone _______________ Cell Phone: _________________ Can we send you
text messages? ___ Yes ___ No
Personal E-Mail ______________________
MySpace URL_________________ Facebook URL ___________________
(Please Print) (Please Print) (Please Print)
Are you a U.S. Citizen? ___ Yes ___ No If no, permanent resident ___ Yes ___ No
If no, please provide registration number ____________________
Do you have a physical or mental impairment which substantially limits one or more major life activities such as: seeing,
hearing, speaking, walking, learning, or working? ___ Yes ___ No
If yes, are you registered with the Access & Disability Services on Campus? ___ Yes ___ No
Educational Goals/Challenges:
1. Who is your Faculty Advisor? ______________________
2. What careers are you interested in? ____________________________________________________________
3. What weaknesses or life challenges do you have that will hinder you from accomplishing your goals?
__________________________________________________________________________________________
__________________________________________________________________________________________
4. (Optional)* Have you ever been charged and/or convicted of a crime?__________________________________
5. Check any degrees / certificates that you are enrolled in or currently have
___ Diploma/Certificate ___ Associate (AA or AS) ___ Associate Applied Science (AAS)
___ Adult/Continuing Education
If GED, what semester do you anticipate becoming a full-time student? Spring
□ Summer □ Fall □ N/A □
6. Anticipated Graduation/Completion Date_________ Major(s) _________________ Minor(s) _________________
7. Are you planning to transfer to a 4 year college or university? ___ Yes ___ No
8. If yes, please list intended transfer institution(s):
____________________________ ______________________________ __________________________
9. Are you enrolled as a full-time student at HCC? ___ Yes ___ No
