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.     Supervisorís 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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