Mentor's Name
(first last)
Preferred Phone
Alternate Phone
Street Address
Zip Code
Email Address
Please provide your preferred Polo Shirt size
What is your profession?
If employed, who is your
current employer?
What is your current job title?
Please provide a brief
description of your
professional or
occupational  duties and
List any special talents
you may possess (music,
graphic arts, poetry, etc.)
Please check the discussion topics you are most interested in facilitating. We will convene a
facilitation training session to review the discussion scenario, objectives, and mind-map of
expectations.  We also hope you will participate in the Networking Reception.
Mentoring and Networking
Goal Setting
Dress for Success
Police Interactions
Mental Health Considerations
Sexual Behavior
Money Matters:  Financial Literacy
Health Matters
What it Means to Serve
Social Media:  Leadership Implications
Thank you for being part of the 2021 Leadership Development Institute!
Discussion Facilitator/Mentor Registration Form
Alpha Phi Alpha Fraternity, Inc., Eastern Region
2021 Leadership Development Institute
Thank you for agreeing to participate as a discussion facilitator/mentor in the
Leadership Development Institute.  In order to maximize your effectiveness, please take a
few minutes to complete this form so we may be able to best match you with most
appropriate discussion group and breakout room during the networking reception.