Application

Thank you for your interest in mentoring for Danbury Schools & Business Collaborative (DSABC) program(s).

Kindly complete the following application to begin the mentor screening process. 

NOTE(Please disregard the "availability" section of the application - meeting days/times will be arranged at time of match, pending student's availability.)

 
 

 The mission of Danbury Schools And Business Collaborative (DSABC) is to help Danbury Public School students achieve personal and academic success through school based mentoring.

 

Basic Information
Prefix
* First Name
* Last Name
Email Address
Contact Information
Home Address 1
Home Address 2
Home City
Home State
Home Zip Code
Home Phone
Mobile Phone
Work phone
Preferred Method of Communication
Home PhoneCell Phone
Work PhoneEmail
Basic
* Date of Birth
Photo
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Motivational Factors
Demographic Information
* Gender
Primary Language
Other
Secondary Language
Secondary Language Other
Ethnicity
Other
Availability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Interests
Skills/Interests
Career Focused Interests
Career Focused Interests Comments
Mentor Preferences for Match
Age Range
Referral
Recruitment Source
Documents
Document Type 1
Document 1
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Document Type 2
Document 2
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Program Questions
* Name of employer:
If other, please enter here:
Secondary Email Address
Please list any schools that you prefer to mentor at:
* Do you have a gender preference?
* What do you feel are your strengths (bilingual, skills, previous relevant volunteer experience, etc.) that you can bring to this program and why have you chosen to participate in the DSABC mentor program?
* Have you ever been convicted of a criminal offense or charged with any offense against a child?
Electronic Signature
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By signing above, as a  volunteer mentor in the DSABC Mentor Program(s),I agree to:

 ·         mentor for one hour per weekly for a minimum of one school year.

·      accept my assignment with an open mind.

·         attend required training session

·     notify the school office if I am unable to keep my weekly session.        

·         accept and/or ask for assistance from the school liaison, my student's teacher and/or support staff.

·         keep matters confidential regarding my student and his/her family, unless this poses a threat to themselves or someone else

·         notify the DSABC Director of any changes in my employment, address, and telephone number.

·         notify my liaison or the DSABC Director of a desire to change the student I am working with

·    notify my liaison or the DSABC Director if I can no longer continue.

·         conduct all individual mentoring activities in a public or semi-private  area in full view of school staff                                                                    

   MENTOR RELEASE STATEMENT

I, the Undersigned, hereby state that if accepted as a Mentor, I agree to abide by the rules and regulations of the DSABC Mentor Program.  I understand that the program involves spending one hour each week at the assigned school with my mentee from September to June at the assigned location.  Further, I understand that I will attend an orientation session, be involved in training during the year, and communicate with the school liaison regularly during this period.  I am willing to commit one school year in the program and will then be asked to renew for another year. I have not been convicted, of any felony or misdemeanor, classified as an offense against a person or family, of public indecency, or a violation involving a state or federally controlled substance.  I am not under current indictment. Further, I hereby fully release, discharge, indemnify, and hold harmless the DSABC Mentor Program, Danbury Public Schools, participating organizations and all of the foregoing's employees, officers, directors, coordinators, Board members and agents from any and all liability, claims, causes of action, costs and expenses which may be or may at any time hereafter become attributable to my participation in the DSABC Mentor Program.

I understand that program staff reserves the right to terminate a mentor from the program with or without cause.  I understand that the DSABC Mentor Program and relationships established take place only on Danbury school property within the confines of the school day and occasional Program sponsored and organized activities. This program does not encourage, condone, or approve of relationships established between mentor/mentee and family members beyond the school day and Program organized activities.  Any such contacts are prohibited as outside the scope of the program and could result in the termination of the participation of the mentor in the program.

I give permission for Mentor staff to conduct a criminal and DCF background check as part of the screening for entrance into this program.  This may include verification of personal and employment references as well as a criminal check with the local authorities.

I have read the above Mentor Agreement and Release Statement and agree to their contents.  I certify that all statements in this profile application are true and accurate.