Volunteer Mediation Information Form

 

 

 

Date Submitted: _______________

 

 

1.      Name:_____________________________________________________________

 

2.      Campus Address: ___________________________________________________

 

3.     Day Time Phone: _______________  E-Mail Address: _________________________

 

4.     Department:  _______________________ Job Title & Grade: ________________

 

5.     How long in this position? ______years          How long at UNM? ______ years

 

6.     Supervisor Name & Title:  ______________________________________________

 

7.     Have you talked with him/her about your desire to be a member of the staff mediator pool? 

 

Yes _________   No _________

 

8.     Supervisor’s Approval ________________________________   Yes  _____    No ______

                                                           Signature

 

9.     Are you proficient in any languages other than English?  Yes____  No______

If yes, which one(s)? _______________

 

10.                          If you presently have a mediation certificate, please attach a copy.

 

11.                          Have you ever done formal mediations (for a particular program or department)?   Yes_____   No ________

 

If yes, please describe for what program or department and approximately how many mediations you have done?

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