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"We don't see things as they are, we see them as we are." ~Anais Nin

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Application for
Basic Volunteer
Mediation Training

1. Please provide the following contact information:

First Name

Last Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

URL

Date of Birth

Gender Male Female

2. How long have you lived in the Knoxville area?

3. Your background (fill out all that apply):

4. Highest grade completed
high school
some college/university
graduated from college/university
graduate work
graduate degree

5. Schools attended (post-secondary):

6. Employment
currently employed
student
retired
other

7. Do you speak a language other than English? If so, what languages?

8. Do you have cultural experiences which you think would help you in your work as a volunteer mediator in our community? (Please feel free to write as much as you want.)

9. Volunteer experience: Have you ever volunteered for an organization which provides services to the public?

yes
no

If yes, for what organization did you volunteer?

10. Other background information you would like to share with us

11. Why do you want to become a mediator?

12. Have you ever participated in a mediation?

yes
no

If yes, please describe the circumstances of your participation:

13. If you know, please check the times you will be available, as a general rule, to mediate: (Check all that apply)
Mon-Thurs mornings, 8:30am-12 noon
Mon-Thurs afternoons, 1pm-4pm
Mon-Thurs evenings, 6pm-9pm
Friday, daytime
Saturday, daytime

14. Please tell us about any specific times when you will not be able to mediate:

15. Anything else you'd like to tell us about yourself:

16. Do you have any questions about the application process?
Is anything in the form unclear?

Copyright � 2007 CMC. All rights reserved.
Revised: 11/19/09

community mediation center :: 912 South Gay Street :: Suite L300 :: Knoxville, TN 37902 :: P865.594.1879 :: F865.594.1890 :: info@2mediate.org

Copyright � 2007 CMC. All rights reserved. Revised: 11/19/09

Copyright � 2007 CMC. All rights reserved.
Revised: 11/19/09