Personal Information

Mediation Experience

( Note: Mediations are scheduled Monday - Friday at 9:00AM, 9:30AM, 1:00PM, and 1:30PM )


if "Yes," where?

 ADR Armed Forces Attorney Business/Finance Clergy Construction Education (K-12) Education (University) HR IT Law Enforcement Marketing/PR Medical Paralegal Real Estate Social Work Other


Please list two persons, not related to you, and you have known at least one year.

Reference 1

Reference 2


High School:




Emergency Contact


Please read the following, sign, and date.

I affirm that all information given is true to the best of my knowledge.

I agree to abide by all obligations and rules relevant to service as a volunteer mediator of DRS NORTH TEXAS INC.

I understand that:

a) my services as volunteer mediator for DRS NORTH TEXAS INC. is a privilege; and

b) knowingly submitting false information and/or failing to abide by DRS NORTH TEXAS INC. established standards of performance and/or behavior may result in dismissal from the Volunteer Mediator Program at the sole discretion of DRS NORTH TEXAS INC.

I grant permission to DRS NORTH TEXAS INC.:

a) to post photos, video, or other items of me while volunteering or attending a DRS event on their social media accounts, websites, and printed marketing materials, hereinafter referred to as "Materials";

b) I release the agency, the agency's representatives, employees, managers, officers, and directors, from all claims and demands arising out of or in connection with any use of said "Materials"; and

c) I acknowledge and agree that no sums whatsoever will be due to me as a result of the use of the "Materials" or any rights therein.