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PEER MEDIATION PROGRAM MEDIATION REQUEST FORM

If you wish to request mediation services, please fill out the form below and click Submit Request. You may also download and print the form. Remember to bring or mail the printed form to the Peer Mediation Program, 1130 Shriver Lab, East Wing, College Park, MD 20742.

Information on You

Name:
Email:
Phone:
Address:
Address 2 :
City, State, Zip	,

Your Demographic Information

Race / Ethnicity:
Sex / Gender:
Sexual Orientation:
Religious, Spiritual, Faith-Based, or Secular Affiliation:
Academic Year:
Referral Source:

Description of the Situation

Please enter a brief description of the situation for which you are seeking Peer Mediation:

Any previous action on this situation? (e.g., legal action, small claims, campus judicial programs, R.A. involvement, security called, union role)

Yes. Please describe:
No

Scheduling

When are you available for mediation? (e.g., time, days)

Information on Other Party/ies Involved

Party #1

Name:
Address:
Phone:
Email:
Race / Ethnicity:
Sex / Gender:
Sexual Orientation:
Religious, Spiritual, Faith-Based, or Secular Affiliation:
Academic Year:

Party #2

Name:
Address:
Phone:
Email:
Race / Ethnicity:
Sex / Gender:
Sexual Orientation:
Religious, Spiritual, Faith-Based, or Secular Affiliation:
Academic Year:

Your request will be submitted by email to the coordinator of the PMP program. You will receive an email "receipt" within 48 hours of submission.

Questions about the Peer Mediation Program can be addressed by the PMP Coordinator at ohrp-mediation@umd.edu.