Brock Mentorship Program Appointment Form

Mentorship Program Appointment Form

Brock University recognizes the value of a mentorship program involving senior high school students volunteering as protégés in a research study or investigation in a specific discipline within the Faculty of Mathematics and Science, Applied Health Sciences and Social Sciences under the supervision and guidance of a faculty member or permanent staff member.

Involvement in the Mentorship Program is intended to provide a rewarding experience for all participants – protégé and mentor. Science laboratories, field research, and other research activities often do involve risk to the participants. Brock University is committed to ensuring that the research of its members is carried out in a safe and responsible manner. Hence, while Brock encourages protégés to engage in the Mentorship Program it does so under conditions intended to minimize the risk to the health, safety and security of all individuals and to identify clearly the responsibilities of University, University employees and their protégés.

The following are conditions under which individuals may participate as protégés within this Program.

The Department Chair and the Dean of a Faculty must authorize in writing the protégé to take part in a specific Faculty activity. This authorization will only be provided after the conditions described herein are satisfied. The duration of the authorization will be specified but will not be greater than twelve months.

Each protégé must be supervised by a Mentor who is a Brock University faculty member or full time staff member. Protégés are not permitted to access laboratories or to participate in field research work without the supervision of the faculty Mentor or another, appropriately qualified and responsible individual. The Mentor must agree to accept the health and safety responsibilities of the supervisor detailed in Appendix 2.

Each protégé must participate in all required WHMIS; environment, health and safety training; and training in the use of any apparatus prior to starting their assigned activities. The Mentor is required to certify in writing to the Chair the training required and the date at which the training was received. The Environment, Health and Safety Officer may be requested to provide advice on the training required.

Where use of animals is involved, the protégé is required to participate in a University-sponsored course in the use of animals. The Animal Care Technician is required to certify in writing that the protégé has received the required training and education. The faculty Mentor is required to obtain necessary Animal Care and Use Committee approval prior to the start of the project, as appropriate.

Each protégé and her/his parents and/or legal guardians will sign a statement relinquishing Brock University of any legal responsibility should the protégé be injured while taking part in the approved research activity. The protégé will be required to accept responsibility for adhering to all University or laboratory requirements related to Good Laboratory Practices and the health and safety of the protégé and other individuals who may be engaged in research activity in the laboratory or surrounding environment.

Where the research or investigational study involves human participants as defined by University policy, the faculty Mentor is responsible for ensuring the protégé is familiar

with University policies related to the involvement of human subjects in research and is required to obtain necessary Research Ethics Board approval prior to the start of the project.

Each protégé and Mentor are required to discuss and agree in advance to the disposition of any intellectual property that may arise from the research activity. The Office of Research Services is available for consultation.

Description of the Mentorship Project:
(Specify parameters of the research activity; the required training including WHMIS, use of apparatus or care of animals; the dates of the projects; and the degree of access required.)

Acknowledgement of Responsibility of the Mentor:
I agree to supervise and provide mentoring to: ……………………………………….. as my protégé in the Mentorship Project described above. This supervision includes the duties and responsibilities to the protégé as outlined in Appendix 2. I further agree to supervise the protégé’s work closely until he/she has reached an appropriate level of competence in her/his assigned tasks. I will ensure that the protégé is supervised in all activities by myself or a qualified co-supervisor. (Competence is defined as being qualified because of knowledge, training and experience to perform the work; being familiar with the health and safety rules and regulations that apply to the activity, having knowledge of all potential or actual dangers that could develop in the work, and being familiar with Brock’s emergency response system.)

NAME :
Signature of Mentor:
Date:

Acceptance of Responsibility as a Protégé:
I have read, understand and accept the duties and responsibilities of a protégé as outlined in Appendix 1 in the context of my participation in the Mentorship Program at Brock University. I agree to be subject to the authority of Brock University and of ……………………………………… as my Mentor. In addition, I agree that the University may terminate my involvement as a protégé at any time and without any commitment to provide a reason.

Protégé Name:
Signature of Protégé:
Date:

Liability Release:
We have read and understand the conditions under which protégés may take part in Brock University activities and we are aware that there may be risks inherent in the activity for which …………………………………… is being mentored. As a consideration of Brock University accepting …………………………………….. as a protégé in the specific activity described above, we, on behalf of our heirs, executors, administrators, successors, and/or assigns, agree to and hereby release Brock University, its employees, agents, affiliates, scientific staff, and cooperating institutions from, and agree to indemnify and hold them and each of them harmless against, any and all liabilities they may jointly or severally incur to ……………………………….. her/his heirs, executors, administrators, successors, and/or assigns, in respect of any claim, suit, or cause of action, including attorney’s fees and expenses of litigation, including any such injury, loss of health, financial loss, or damage to property, including any such injury, loss or damage resulting from the negligence of Brock University, its employees, agents, affiliates, scientific staff, and/or cooperating institutions, directly or indirectly by …………………………… participation in the aforementioned Brock University activity. However, we do not release any Brock University employee, agent, affiliate, scientific staff member, or cooperating institution from liability on account of any injury, loss, or damage to ……………………………… directly caused by the gross negligence of that employee, agent, affiliate, scientific staff member or cooperating institution.

Protégé Name:
Signature: Date:

…………………………………… is granted permission to participate in the Mentorship Program in the specific activity described above under the supervision of …………………………………....

This authorization is valid from ……………………….……... until ………………..….………..…. (no more than 12 months.)

Department Chair/Signature and Date:

……………………………………………………………………………..

Dean’s Name/Signature and Date:

…………………………………………………………………………….