Volunteer Application Form

Full Name

Role Applied for

Home Address

Home Telephone Number

Mobile Telephone Number

Email Address

Where did you hear about the opportunity to train as a volunteer mediator?

Work History

Employer

Position held & duties

Dates employed

Reason for leaving

Suitability (if applying for mediator role)

a) What do you understand/ know about community mediation?

b) What interests you about becoming a mediator and what qualities do you feel you have that would help you within the role?

c) Describe what previous experience/relevant skills you have that you feel relate to mediation

d) What time commitment would you be able to give to mediation/the Service?
 Daytimes Evenings Weekends


e) Are you prepared to attend 6 mediators’ meetings per year, usually taking place in the evening in Leatherhead and to help from time to time with promotion/ publicity activities?
 Yes No


f) Do you have your own transport to travel to meetings, which could be anywhere in Epsom & Ewell or Mole Valley?
 Yes No


g) Do you have any other skills that may be useful to Mid-Surrey Mediation Service and would you be prepared to devote time to putting them to use on behalf of the Service either as a member of the management committee or otherwise?

Suitability (for any other role)

h) Please summarise past relevant experience

References (last employer or people who have known you for at least two years)

Reference 1

Name

Address & Postcode

Email Address

Telephone Number

Reference 2

Name

Address & Postcode

Email Address

Telephone Number

On successful completion of the training course, if required, I consent to having a criminal record check via the Disclosure and Barring Service (DBS).
 Yes


I confirm that to the best of my knowledge the information given on this form is correct.
 Yes


Please answer the sum: