Northern Illinois University
Student Mediation Services

Request for Mediation - Initiator


I ____________________________________, as the initiator of mediation, am requesting that the following matter be considered for mediation.

  • I understand that the other party(s) must also agree to mediation.
  • I understand that the Judicial Affairs reserves the right to determine which matters are appropriate to mediate.
Brief summary of the dispute:
 

My "Agreement to Mediate" form is signed and enclosed.
I have enclosed a copy of my school and employment schedule. Mediation will be scheduled based on the availability of all disputing parties' schedules and the availability of the mediator(s) schedule. The mediator(s) assigned to this matter will be randomly selected.


Signature
Printed Name
Date


Parties involved in dispute: (please included yourself and all parties)
Name Address Phone

Return to Student Mediation Services (Grant Tower A, 2nd Floor)