Peer Mediation Request - Kewaskum School District

Peer Mediation Request

What is Peer Mediation?

Peer mediation is a conflict resolution strategy. Peer mediation invites students (disputants) to take responsibility for their actions by working together to find solutions to conflict. It involves two trained students (mediators) leading the disputants through a structured process. The mediators do not take sides and conflicts mediated remain confidential.

Use the form below to request Peer Mediation.

Peer Mediation Request Form:

Today's Date

Names of students in conflict.

Where did the conflict occur?

(1 required)

	Bus			Cafeteria
	Classroom			Outside of School
	Bathroom			Hallway
	Gym/locker room			Other

If you selected "other" as a response to the previous question, please explain.

Briefly describe the problem:

Mediation requested by (select one):

	Student			Teacher
	Parent			Assistant Principal
	Principal			Other

If you selected "other" as a response to the previous question, please explain.

Name of person requesting mediation.

Type in the text that you see above:

Last Updated: 10/22/10

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