DeKalb County - 100 Black Men

LEADERSHIP ACADEMY

Name: ______

Birth Date: ______Grade: ______2005-2006

School: ______

DeKalb County Chapter of 100 Black Men

3951 Snapfinger Parkway, Suite 315

Decatur, GA 30035

404-288-2772

Emergency Contact on Back of Badge

Please Print Clearly

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Student’s Home Address City, State Zip Code

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Mother/Guardian Name Occupation

(_____) ______(_____) ______

Home Telephone Work Telephone

______

Mother’s Address (If different than student’s) City, State Zip Code

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Father/Guardian Name Occupation

(_____) ______(_____) ______

Home Telephone Work Telephone

______

Father’s Address (If different than student’s) City, State Zip Code

E-mail address______Student’s e-mail address______

______

Emergency Contact Daytime Telephone


DeKalb County Chapter of 100 Black Men of America, Inc.

LEADERSHIP ACADEMY FOR BLACK MALES

New Student Application

(To be completed by STUDENT)

Please have your son complete the items listed below by placing a check (ü) by the appropriate response. It is essential that we have this information completed in order to plan for the remainder of the year.

  1. I will attend all seminars ___ Yes ___ No
  1. I will show respect at all times and use the proper titles

when addressing others (Example: Mr., Ms., Sir, Madam) ___ Yes ___ No

  1. I will listen when others are speaking ___ Yes ___ No
  1. I will speak up when asked a questions or asked for my opinion ___ Yes ___ No
  1. I will learn ___ Yes ___ No
  1. I will teach ___ Yes ___ No
  1. I will create and maintain a neat notebook ___ Yes ___ No
  1. I will complete all assignments ___ Yes ___ No
  1. I will communicate weekly with my group leader ___ Yes ___ No
  1. I will serve as a role model for other students ___ Yes ___ No
  1. I want to be a member of the Leadership Academy because ______
  2. I am very good at ______
  3. I need to be better at ______

Student’s Signature ______Date ______


DeKalb County Chapter of 100 Black Men of America, Inc.

LEADERSHIP ACADEMY FOR BLACK MALES

New Student Application

(To be completed by PARENTS/GUARDIANS)

This page is to be completed by the parent or guardian legally responsible for the young man applying to the Leadership Academy. Please respond to all of the items below pertaining to the young man applying for the Leadership Academy. This information will be used to make selection decisions for membership into the Leadership Academy.

_____ My son will actively participate in the Leadership Academy.

_____ My son will not participate in the Leadership Academy.

_____ If my son is selected, I will attend Parent’s Meeting(s)

_____ If my son is selected, I will not be able to attend the Parent’s Meeting(s)

Child’s strengths ______

______

Child’s weaknesses ______

______

Child’s willingness to carry out responsibilities at home ______

______

Name Child’s Insurance Carrier: ______Policy No. ______

Uniform Sizes: Trousers ______Sweater Vest: q SMq MDq LGq XL

(Uniforms provided by the Leadership Academy consist of navy blue trousers, a gray sweater vest, and a red & blue tie. It is to be worn with a white shirt and black or dark shoes – to be provided by his parents. A black notebook will also be provided by the Leadership Academy.)

Please check below the area(s) in which you will participate with the Leadership Academy:

____ Attend Parent Workshops ____ Participate in Fundraiser

____ Coordinator of Parent Program ____ Present one or more seminars

Comments ______

______

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Parent’s Signature ______Date ______

Dear Parent:

Attached is the Leadership Academy Application form for you and your son to complete, for possible admittance into the Academy. The Leadership Academy has been in existence for the past 9 years. It is designed to help teach students in grades 4 through 7 learn leadership skills. In addition, our PC Academy for students in grades 8 through 12 is designed to enhance and develop technology skills as well as promote leadership skills. The young men are expected to use their skills at home, in school and in the community. The program is selective. Everyone making application is not chosen to participate in the program. We expect a commitment from both the young man and his parent(s).

The Leadership Academy has received high praise from educators and members of the community. Successful participation in the Academy will allow students to receive full scholarships to Talladega College upon graduation from high school, based on their presentation, academic and personal achievement.

Enrollments are limited, therefore, this application form must be completed in its entirety and returned to the DEKALB CHAPTER 100 BLACK MEN OF AMERICA, INC. Please contact Ms.Kim M. Warren at (404)288-2772 if you have any questions.

Thank you,

Leadership Academy

Coordinating Committee

Omega World Center 3951 Snapfinger Parkway Suite 315 Decatur, Georgia 30035-3203

Office (404) 288-2772 Fax (404) 288-0107