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Peer Mediator Re-commitment Form
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Email
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Your email
What is your grade level?
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Choose
10th
11th
Senior
List your elective classes only for 1st semester. I need to know when you are available for tours, peer mediation, etc. Also when is your lunch period.
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Your answer
Peer mediator duties are mostly held during the school day. Do you agree to attend all events (lunch & learns, sign up days, new student orientations, fundraisers, etc.)
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Yes, I will make every effort to attend each peer mediator event. I acknowledge that if I miss more than 2 events this could result in me being removed from the peer mediator organization.
No, I will not be returning as a peer mediator for 2022-23.
I agree to pay $20 mandatory membership fees as a returning peer mediator.
Yes
No
Clear selection
3. I agree to keep all matters discussed with me as a peer mediator confidential unless there is disclosure of suicidal thoughts or actions, abuse, and/or hurt / harm to any individual. Then this information will be reported directly to the sponsor.
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Yes
No
I agree to use my peer mediator pass for official peer mediator business only. I further understand that any misuse of the pass will result in immediate dismissal from the peer mediation organization.
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Yes, I agree
No, I decline continuing as a peer mediator.
I agree to attend mandatory peer mediator training.
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Yes, I agree
No, I decline continuing as a peer mediator.
T-shirt Size in Adult
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Small Adult
M Adult
L Adult
XL Adult
XXL Adult
XXXL Adult
4XL Adult
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