Dignity at Work and Study

Application Form
Mediator (Voluntary unpaid)

Name
		
Job Title
		
Work Address

		
Telephone number/Email address
		
Name and signature of Head of Department or equivalent
		
You must have the permission of your line manager before applying for this role. This includes gaining permission to take time off during the working day to perform this role. If returning this form by email please type their name here, this will be seen as their permission for this application.	
Have you ever carried out a similar role or undertaken training that would be relevant to this role?		
Please indicate whether you would prefer to support staff and/or students in this role		
Mandatory training will take place on 4th, 5th, 11th and 12th November 2009. Please indicate whether or not you are available on these dates.		

Please provide a brief summary of why you are interested in this role	

	
Please give brief details of any experience you have which demonstrates the following skills or experience:
	
Able to adopt a flexible approach and respond creatively to problem solving 

	
Effective verbal and listening communication skills

	
Able to gain trust and respect	
Able to act impartially in a non-judgmental way
	
Experience of dealing with a diverse range of individuals at all levels
	
Able to maintain confidentiality
	
Please provide any further information relevant to your application

	
Please provide the contact details of one referee that we can ask about your suitability for this role