ࡱ>  Root Entry@ @MatOST  MMMN0NDP0p(=/dT CONFIDENTIALITY AGREEMENT FOR THE BGLAD NETWORK The purpose of this agreement is to ensure that the privacy and confidentiality needs of all members of the group are being met and respected. I agree to respect each individual's need for privacy and where he/she is in terms of being "out." I will not share/repeat the names of individuals participating in this group outside of this group without that individual's explicit permission. I will not share another's personal experience or confidence (inside or outside of this group) without that individual's explicit permission. When talking about the group or sharing general learnings from the group, I will exercise extreme caution and discretion to protect the group, as a whole, and the individuals involved. Name_______________________________________ Date_____________________ Business ________ ___________________________ Site______________________ MEMBER INFORMATION Please answer all questions. Communication: Information is circulated to the network primarily via e-mail but occasionally paper mail is the only option. Members who do not want to receive e-mail at work may request e-mail at home or paper-mail-only communication. Please fill in the appropriate blanks below for BOTH #1 and #2: 1. ____ It's OK to send me e-mail at work. My e-mail address is:  (internal DuPont address) ______________________________ ** OR ** ____ Please do NOT send me e-mail at work. Send me e-mail at:  (internet address) _____________________________________ ** OR ** ____ Please do NOT send me any e-mail. 2. ____ It's OK to send me paper mail at work. My work address is:  ______________________________________________________ ** OR ** ____ Please do NOT send me paper mail at work. Send paper mail to me at: ___________________________________________ ___________________________________________ NOTE: If you have an administrative assistant, secretary, etc., who may read your email or paper mail, s/he needs to sign a non-member confidentiality agreement. The purpose of the agreement is to make him/her aware of the sensitivity of BGLAD communications. If you need a copy of this agreement, please check the space below: ____ Please send a non-member confidentiality agreement to: _________________________________ (yourself or your assistant) Demographics: Please check the appropriate blanks below: (1) Gender: ___Female ___Transgendered Female ___Male ___Transgendered Male (2) Sexual orientation: ___Bisexual ___Gay ___Lesbian ___Heterosexual (3) If you are joining as an Ally (i.e., you are not Bisexual, Gay, Lesbian, or Transgendered), please indicate your level of participation: ___Supporter ___Advocate "Supporters" and "Advocates" are defined in the Bylaws as follows: SUPPORTERS shall provide emotional support to members and continue to learn about issues of concern to people who are bisexual, gay, lesbian, or transgendered, and educate others. ADVOCATES perform the same functions as Supporters but in addition they: Are available to intervene on members' behalf Exercise their influence Commit time to BGLAD activities and events Visibly work to advance the mission of BGLAD Publicly speak out on behalf of people who are bisexual, gay, lesbian, or transgendered Privacy: If you are BISEXUAL, GAY, LESBIAN, or TRANSGENDERED and are willing to be identified to the members of BGLAD, please check the statement below. If you do NOT check this statement, your name will be kept CONFIDENTIAL (known only to the Network Liaison and the Membership Coordinator) as specified in the Bylaws. ____ I am willing to be "out" to the members of BGLAD. I give the BGLAD Steering Committee permission to publish my name within the BGLAD network. No B/G/L/T member's name will be revealed to anyone outside the BGLAD network without his or her explicit, written permission. The statement above does NOT give permission to publish your name OUTSIDE the network. "Mentoring": If you would like a current member of BGLAD to help you learn about BGLAD, sexual orientation issues, etc., please check the statement below: ____ Please match me up with a BGLAD "mentor." Comments/requests (e.g., what type of mentor would you prefer - B, G, L, T, ally, male, female; etc.; what you would like to get from the relationship): _________________________________ _____________________________________________________________________________ And finallyPlease tell us how you heard about BGLAD: ____ Know a current member ____ Heard about us from co-workers (non-members) ____ Read about us within DuPont ____ Read about us in local (Wilmington) press ____ Referred to us by DuPont HR or EAP ____ Other ______________________________________________________ Thanks! Welcome to BGLAD! 51;~ ysmsmgmgmgmgmgmgmg8    ` k  " bj ) npypyjyjyjyjyjyjyjy57-O  SUqggRRRRhh  !  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