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2. Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Daytime Phone*
11. Evening Phone
13. Cell Phone
14. Email*
16. Method of Contact Preference*
18. Why are you interested in becoming a mediator and/or mediation training, at this time?
20. Do you have any prior volunteer or mediation experience?*

    1. Yes

    1. No
22. If yes, tell us your experience.
24. VOLUNTEER DEMOGRAPHIC INFORMATION
26. Race
    -- Select One --Black/Afican AmericanWhite/CaucasianHispanic/LatinoNative American/Alaskan NativeNative Hawaiian/Pacific IslanderTwo/More RacesAsianUnknown
27. Household Income Range
    -- Select One --$0-$14,999$15,000-$24,999$25,000-$34,999$35,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$149,999$150,000 and over
29. Education
    -- Select One --1st-8th GradeHigh School/GEDSome collegeTech/Vocational training2-year college/proof of certificate4-year college degreeGraduate degree
30. Marital Status
    -- Select One --DivorcedMarriedSeparatedSingleUnmarriedWidowed
32. Age
    -- Select One --0-1920-2930-3940-4950 +
33. Work status
    -- Select One --Full-timePart-timeSelf employedUnemployedRetired
35. What languages do you speak?
36. Military Status
    -- Select One --ActiveRetiredSpouseN/A
38. What skills do you possess that lend to your ability to become a good mediator?*
40. Do you have any personal experience with the mediation process?*

    1. Yes

    1. No
42. If yes, tell us your experience.
44. Educational/Occupational background:
46. Would you be able to commit to at least a year of service and training?*

    1. Yes

    1. No
48. You must attend all of the 45 classroom hours to complete the course. This is skills-based training and there can be no missed hours. Notifications of scheduled mediations are sent via Email; therefore Mediators are required to have email access and the ability to promptly reply to requests.
50. 1. Please check if you understand and agree to this commitment.
52. If you have any questions please call the Community Mediation Program at 410-638-4807 or mediation@harfordcountymd.gov.
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54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

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