Peer Mediator Application Form

Please provide the following information and return the completed application to Ms. Henry by
Friday, June 5th!
Name: _________________________ Grade: _________ E-Mail:________________________
Please feel free to use the back of this application to provide more detail to the following questions:

1. List the activities you are involved in inside and outside of school:

2. Describe what your role as a Peer Mediator will be at CCHS:

3. Why would you be an effective Peer Mediator?

4. What are your interests?

5. How are you PRO-active? Give examples:

6. List five adjectives that you would use to describe yourself:

Please note: You MUST be able to commit to the full 2-day mediation training in August
and bi-monthly meetings throughout the school year, in addition to regular Peer Mentor
duties. Can you commit? If yes, please sign below and have your parent sign too!
Student Name: _________________________________

Date: ___________________

Student Signature:_______________________________________________________________
Parent Name:___________________________________

Date: ___________________

Parent Signature: _______________________________________________________________