First Name
    Last Name


    How do you prefer to be contacted? Cell PhoneHome PhoneEmail

    Cell Phone
    Home Phone


    Do you check email regularly?
    How did you hear about CCCMC?

    Do you speak any languages other than English?YesNo
    If Yes, what other languages so you speak fluently?
    Why do you want to become a mediator?
    Which skills do you have that would make you a good mediator?
    CCCMC is a community-based program. What experience do you have which demonstrates your commitment to community?
    What other volunteering have you done? What was the time commitment to that work?
    What times during the week are you available to mediate? (please remember you need approximately 4 hours per session)