Mediator Volunteer Application Form

Mediator Volunteer Application Form
Thank you for your interest in volunteering with WMS.

We ask all prospective volunteers to complete the form below and attach your up to date CV, and certificate of your mediation training.

All data submitted is governed by our Data Protection Policy. By submitting personal information to us you agree to these terms.
About you
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (0) 0000-000000.
Email
example@example.com
1. Which of our panels are you interested in joining? (Please tick all that appropriate)
2. Why are you interested in volunteering for WMS and what do you hope and expect to gain from the experience?
3. Please set out any experience you have had of mediating, as well as any other relevant qualifications or courses you’ve completed.
4. What personal qualities and abilities would you bring to WMS? This may include any experience, qualification or achievement that might have a positive impact on your volunteering at WMS.

5. What times of day/evening would you be available to volunteer with us? Please tick all that apply.

Rows	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

6. We work within the London Borough of Wandsworth. Volunteers are expected to travel within the borough and to hold mediations at our office which is at St Mark’s Durie Hall, Battersea Rise, SW11 1EJ. Please indicate below your preferred/available methods of transport.
7. WMS is committed to ensuring that all reasonable steps are taken to provide for the health and safety of our volunteers. Volunteers are also expected to take reasonable measures to safeguard their own health and safety. Please provide details below of any condition(s) that may restrict the range of tasks that you can undertake:
8. How did you hear about us?

Other
9. Training

Please set out details of your mediation training.
Course title
Course provider
Date of completion of course

DayMonthYear
Date
I attach my training certificate
Please attach your training certificate

Cancelof
Please attach your CV

Cancelof
10. Referees

We ask all prospective mediators to provide us with two referees who would be happy to provide a reference. One of these referees should be someone who knows you in a professional capacity and the other a friend or family member.
Professional Referee:
Name
Telephone
Format: (0) 0000-000000.
Email or Address
example@example.com
How Referee is known to you
Personal Referee:
Name
Telephone
Format: (000) 000-0000.
Email or Address
example@example.com
How Referee is known to you
Criminal Convictions: Do you have any previous criminal convictions? Criminal records will be taken into account only when the conviction is relevant. Declaring a conviction will not prevent you from being considered for a volunteer role.
If yes, please give details below.
Criminal records will be taken into account only when the conviction is relevant. Declaring a conviction will not prevent you from being considered for a volunteer role.
Declaration: I confirm that, to the best of my knowledge, the information I have provided in this application is correct.
Data Protection Act: I understand and agree that, as part of volunteering with WMS my details may be held in a confidential database that is only used for reasons relating to my volunteering. Details of our Data Protection Policy and Privacy Notice are on our website.
Signature
Date

DayMonthYear
Date
Should be Empty:

Mediator Volunteer Application Form

About you

9. Training

10. Referees