Mediation Foundation Training Application Form

Title: Ms./Mr./Mrs./Dr./Prof:*

Name:

First NameLast Name

Address (where you would like your training pack sent too)*

Street Address

Street Address Line 2

CityCountry

Post Code

E-mail*

example@example.com

Mobile/Contact Number*

This course requires that you have a good standard of written and spoken English. Educational attainment to Level 2 is a requirement of the course and the subsequent course portfolio.

Please confirm you meet this requirement as it is unlikely you will pass the course without it

Yes

Please give a brief outline of your current job role and work experience paid or voluntary*

Educational qualifications*

Have you completed any previous training in any related fields Yes / No*

YesNo

If Yes, please provide details

Please state your reasons for wanting to attend the mediation skills course*

Where did you hear about the course?*

Dates of the course:

Course 1 Online: 24th, 29th and 30th April, 1st , 7th and 8th May 2026 (1 place remaining)

Course 2 Online: 4th, 9th, 10th, 11th, 17th and 18th September 2026

NB: Please make sure that you have the appropriate broadband service in order to attend over the length of the course.

Please indicate below whether you are enrolling for option 1 or option 2

The online elements of the course will be delivered via Zoom. Joining instructions will be sent prior to the start date.

The course will proceed if a minimum of six (6) trainees enrol. If for any reason the course does not proceed, all fees will be refunded as per our terms and conditions (see below for more details).

Course Fees: The cost of the course is £1195.00

The fees costs cover all training sessions and training materials; Participants must attend all of the sessions and complete the course portfolio within 30 days of the end of the course to successfully complete the course.

A £200 deposit is required to secure your place*

All fees paid in full at least 12 weeks prior to the course start date will receive a 10% early booking reduction.

We often have trained mediators requesting to join the course as a refresher - we offer a reduced fee for those already trained - please select the appropriate payment details below.

To receive your certificate of 'Trained Mediator' you must complete the course portfolio. The portfolio will be explained fully on the course and any support required to complete it will be made available to you. The portfolio must be submitted within 30 days of the course end. Late portfolios will incur an £80.00 late submission fee. Please indicate below that you have read and understood this information:

Do you have any learning needs/ or where applicable dietary needs?

If you have selected "Yes" above, please give details of your learning needs?

Payment

If you are self-funding, please indicate how you wish to pay upon submission and acceptance onto the course, below.

I wish to pay:*

In FullVia Payment Schedule (Including deposit)By a SponsorI have previous trained as a mediator (*please contact regarding eligibility for additional discount)

Payment Shedule Terms: (via bank transfer only)

# - Please email us directly at: office@changemakerllp.co.uk.

* - All Applicants can pay up their full course fee at any time up to 3 weeks before the course start date

NB: Dates for the subsequent payments will depend upon the date in which the initial deposit is paid.

I wish to pay by:*

Bank Transfer – (details to be provided upon submission of the completed form).Invoice - Payment due within 30 days of invoice. (Payment in Full Only).I am being sponsored and payment arrangements have already been made.I am being partially sponsored - I will contact you directly for payment terms.I have previously trained as a mediator - Please contact me directly with details of course fee (discount eligibility) and any payment terms.

If you are not self funding please supply details of the full name and address and name of the person or department to which the invoice for the course fees should be sent:

* Cancellation of a course booking, by the participant, will be subject to the following charges

More than six weeks before course begin	Full Refund
Over 2 weeks but less than 6 weeks before course begins	75% of fee payable
Two weeks or less before course begins	No Refund

“The Service” reserves the right to alter or cancel courses.

If “The Service” cancels the course all fees will be refunded.

Signature of applicant:

Date*

Date

Foundation Mediation Course

Mediation Foundation Training Course