Peer Mediation Request Form
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Morton East High School
PEER MEDIATION REQUEST FORM Names of students in conflict: 1._________________________________ ID #__________________________ Grade________ 2._________________________________ ID #__________________________ Grade________
Where did the conflict occur? (Check one) ___ Classroom ___ Hallway ___ Café ___Outdoors ___Washroom ___ Other
Briefly describe the problem:
Mediation requested by: (Check one) ___ Dean ___ Counselor ___ Administrator ___ Teacher ___ Student ___ Other
Signature of person requesting mediation X __________________________________ Please check here if you would like to remain anonymous: _______
Date: __________
PEER MEDIATION REQUEST FORM Names of students in conflict: 1._________________________________ ID #__________________________ Grade________ 2._________________________________ ID #__________________________ Grade________
Where did the conflict occur? (Check one) ___ Classroom ___ Hallway ___ Café ___Outdoors ___Washroom ___ Other
Briefly describe the problem:
Mediation requested by: (Check one) ___ Dean ___ Counselor ___ Administrator ___ Teacher ___ Student ___ Other
Signature of person requesting mediation X __________________________________ Please check here if you would like to remain anonymous: _______
Date: __________
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