Application for Mediation Services

Please fill out the blanks below to the best of your ability.

Applicant Name	(Required)
Address	(R)
City / State / Zip	(R)
Phone Number	(R)
Email	(R)
Name of Second Party
Name of Third Party (if applicable)
Briefly describe the nature of the conflict:	(R)
This application is being made by:	Applicant Only All Parties Other   (R)
Do you agree to the terms below?	Yes No   (R)
Verification (to make sure you're human) Enter the text you see in image (or refresh for new text)
Note: Please do not include any URLs in form.

I/We recognize that the conflict resolution process is a voluntary one. In the event of mediation, any settlement reached will be voluntary between and among the parties. The mediator is neither a judge nor an arbiter and has no authority to force a settlement on parties. A settlement or agreement shall be reached in this case only if the parties agree in writing that the settlement or agreement is fair, in their best interest, and voluntarily undertaken.

The mediator assigned to this case will be a volunteer graduate student, or staff person, who has met the educational and experience requirements of the AIM Program and the Center for Conflict Resolution. The mediator will have access to a supervisor who will provide advice and support for the mediator. Neither the mediator nor the supervisor will provide legal counsel or analysis of any party's legal rights in this case.

All information obtained in this case will be kept confidential unless: (1) all parties agree to release all or part of the information; (2) information regarding potential harm to persons and/or property are revealed; or (3) disclosure of information is required by law.

Mediation offered through the AIM Program and the Center for Conflict Resolution are free to students of Abilene Christian University.

In the event that all parties have not joined in this Application for Services, I understand that the Center for Conflict Resolution will contact the other party or parties and invite them to participate in this process. Further, I understand that the other party or parties will be provided with the information I have provided regarding the nature of the conflict.