Application

DECO Workplace Learning E-Mentoring Program

in collaboration with Danbury Schools and Business Collaborative

Thank you for your interest in the mentoring for DECO Workplace Learning E-Mentoring Program.

Kindly complete this application. If you have been provided with the necessary forms authorizing release for DSABC and State of CT. DCF to run background checks, please upload them to this application. (If you have not received these forms in advance of this application, DSABC will forward them to you upon submission.)

 

Basic Information
* 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
Demographic Information
* Gender
Primary Language
Other
Secondary Language
Secondary Language Other
Other
Availability
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
1. Before School
2. AM Block
3. Lunch
4. After School
5. PM Block
Documents
Document Type 1
Document 1
No file is currently uploaded.
Upload File
Document Type 2
Document 2
No file is currently uploaded.
Upload File
Program Questions
Secondary Email Address
* Have you ever been convicted of a criminal offense or charged with any offense against a child?
* Name of employer:
If other, please enter here:
Electronic Signature
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By signing above, as a volunteer mentor in the DECO Workplace Learning E-Mentoring Program (in collaboration with Danbury Schools and Business Collaborative) , I agree to:

  • mentor for up to half an hour per week consistently for a minimum of one school year.
  • accept my assignment with an open mind
  • attend a training session
  • accept and/or ask for assistance from the DECO director, 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 DECO director of any changes in my employment, address and phone 
  • notify my company or DECO director of a desire to change the student I am working with
  • notify my company or DECO director if I can no longer continue

 

 

 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 30 minutes weekly engaged in activities on  secure online platform, IBM MentorPlace and up to 4 face to face group sessions as I'm available with my mentee from September to June. .  Further, I understand that I will view training webinar and 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.