ACADIA PEER MEDIATION REQUEST

Date____________________

Students in conflict:

Name________________________________Grade/Homeroom____________________

Type of conflict (circle one)

Rumor Threat Name Calling Fighting

Loss of Property Other_____________________________

Where did it occur (circle one)

Bus Classroom Hallway Café

Outdoors Other_______________________________

Briefly describe the problem:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Mediation requested by (circle one)

Student Teacher Counselor Administrator

Monitor/Aide Other______________________________

Signature of person making the request________________________________________