Disputant Information Form (each disputant must complete one)
send by intercampus mail to Shala Garcia, 562 Ryle Hall
Your name: _______________________________ Date:_______________
Personal Background Information:
Race/Ethnicity (optional): ________________________________
Gender (optional): _____________________________________
Age: _______________________________________________
Year in school/years at Truman: ___________________________
Phone Number: _______________________________________
E-mail address: _______________________________________
Place of Residence: ____________________________________
Do you prefer we contact you by email or phone_______________
Times available for mediation (between 6:30 pm and 9:00 pm Monday, Tuesday, and Thursday and from 10:00 am to 4:00 pm on Saturdays):
Monday: ____________________________
Tuesday: ____________________________
Wednesday: __________________________
Thursday: ____________________________
Saturday: ____________________________
Name of other disputant(s) 1. ________________________________________
and relationship: 2. ________________________________________
3. ________________________________________
4. ________________________________________
Names of other involved (if relevant):
____________________________________
Brief description of situation (use the back
side of this sheet if necessary):
Your desired outcome of the situation: _____________________________________________________________________ _____________________________________________________________________
_____________________________________________________________________