My Brothers Keeper Mentee Application
We are excited about your interest in the MBK program. Please answer all the questions below so we can learn more about you.

Note: All interested mentees MUST attend Jack Yates High School.
Email address *
1. First Name:
Your answer
Last Name
Your answer
3. Age
Your answer
Date of Birth
MM
/
DD
/
YYYY
4. Ethnicity:
Parent/Guardian Name(s):
Your answer
Parent/Guardian Relationship to Mentee:
Throughout the program, students may be highlighted in efforts to promote MBK the “Change Happens “Each One of Us” program activities and achievements. For example, students may be featured in materials to train teachers and/or increase public awareness of our program through newspapers, radio, TV, the web, DVDs, displays, brochures, and other types of media. I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions? *
Phone Number:
Please provide your personal phone number if applicable
Your answer
Address:
Your answer
Parent/Guardian Phone Number:
Your answer
Email Address:
Please provide your personal email address
Your answer
Do You Have Any Siblings? If no, skip to the next section.
Siblings Name and Ages:
Your answer
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