Volunteer Mediator Application

 

Today's Date: (dd/mm/yy)
Name:
Address:
City:
State:
Zip:
Home Phone:
Message Phone:
Email address:
Occupation
Do you wish to be considered as a volunteer Mediator Board member Annual Benefit Committee
Education/Training (degrees, other training, relevant experiences)  
Languages spoken:
Do you represent an underserved population? yes no
Experience and Background  
Have you had previous volunteer experience? yes no 
At what organizations?
Services provided:
What attributes do you possess that would enhance your effectiveness as a mediator or mentor?
Why do you wish to volunteer with Mediation Services?
What talents and interests do you possess that makes you an effective employee?
Have you been convicted of a crime (other than traffic violations) or been imprisoned in the last seven years? yes no
If yes, please explain the nature of the offense:
Availability to volunteer: Days Evenings  Weekends
Comments or Additional Information:
If selected as a volunteer, I agree to adhere to the Policies and Procedures of Mediation Services for Anoka County. I agree to complete the required training course and to participate in the required on-going training. If selected as a mediator, I agree to serve for two years as a mediator at which time I can re-evaluate my commitment to the organization. If selected as a mentor, I agree to serve for one year as a mentor at which time I can re-evaluate my commitment to the organization. I attest that the information provided is true and accurate to the best of my knowledge:  

 

yes no

Mediation Services is an equal opportunity employer and does not discriminate on the basis of race, creed, color, national origin, ancestry, sex, age physical or mental handicap, disabled veterans, sexual preference or person receiving public assistance.

2520 Coon Rapids Blvd. #100
Coon Rapids, MN 55433
Phone: 763-422-8878
Fax: 763-422-0808

Remember to print this page prior to submitting your application! See the button -- lower left!