Role Applied for
Home Telephone Number
Mobile Telephone Number
Where did you hear about the opportunity to train as a volunteer mediator?
Position held & duties
Reason for leaving
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?
f) Do you have your own transport to travel to meetings, which could be anywhere in Epsom & Ewell or Mole Valley?
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?
h) Please summarise past relevant experience
Address & Postcode
On successful completion of the training course, if required, I consent to having a criminal record check via the Disclosure and Barring Service (DBS).
I confirm that to the best of my knowledge the information given on this form is correct.
Please answer the sum: