Date*:
Fall*:
Spring*:
Summer*:
Year*:

Name*:

Address:

E-mail:

Home Phone:

Work Phone:

Cell Phone:

Birthday (month/day):

Faculty Part Time

Faculty Full Time Staff Part Time Staff Full Time 
Student Part Time   Student Full Time  Grad Student Part Time Grad Student Full Time
 
Availability (check all that apply)*:
Monday Tuesday Wednesday Thursday Friday Saturday
9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00
1:00 - 4:00 1:00 - 4:00 1:00 - 4:00 1:00 - 4:00 1:00 - 4:00 1:00 - 4:00
6:00 - 9:00 6:00 - 9:00 6:00 - 9:00 6:00 - 9:00 6:00 - 9:00 6:00 - 9:00
Are you bilingual? Yes  No   Languages:
 
Please check the types of cases you are interested in mediating:
Relationship Disputes Money Related Issues Diversity/Cultural Issues
University Related Issues Lease Disagreements Roommate Disputes
Non-University Related Issues ALL TYPES Rollins College
 
In order to facilitate the mediation process, any information you wish to voluntarily share with us would be helpful and appreciated.
Background:
Native American/Alaskan Native Caucasian Asian/Pacific Islander
Hispanic African American Other
 
Age:
16-21 years 22-29years 30-45 years 46-59 years 60+ years
 
Gender:
Male Female      

 

"*" INDICATES RESPONSE IS COMPULSORY

 

 

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