First Name * Last Name * Student ID Number * Email Address * Phone Number * Class Standing Freshman Sophomore Junior Senior Grad Student Major * Career Interest * Enrollment Full-time (12 or more units) Part-time (less than 12 units) Last School Attended Barbershop Time 11am - 12pm 12pm - 1pm 1pm - 2pm 2pm - 3pm 3pm - 4pm 4pm - 5pm After 5pm What time works best for you to attend the weekly Barbershop Talk in person? You can select all that apply. Barbershop Discussion Topics Feel free to share any topics that you would like to discuss during one of the Barbershop Talks. Monthly Event Time 2pm - 4pm 3pm - 5pm 4pm - 6pm 5pm - 7pm 6pm - 8pm What time works best for you to attend a Monthly BMS sponsored event? You can select all that apply. Disclaimer I agree with the terms detailed below I hereby authorize the Black Male Scholars program to collect and compile information about me in the BMS data tracking system. The purpose of the data collection system is to help the program staff monitor the academic performance, plan programs, develop support services, and assess program impacts for BMS members. The information collected such as background/demographic characteristics, enrollment status, academic data (GPA, credits earned, etc.) and BMS activities/events participation will only be reviewed by program personnel. The only people who will have access to my name are my advisor(s) and data system administrators. De-identified data (data without names and other confidential information attached) may be made available to other research institutions. My signature below indicates that I agree to participate in the data collection for the duration of my enrollment at this institution. Furthermore, I understand that if I change my mind, I may write a letter to BMS stating that I revoke my consent for the data collection, which will cease upon receipt of my letter Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.
