First Participant ________________________________

Second Participant ________________________________ Date ______________

I, _______________________, the undersigned, understand that mediation is a voluntary process to which I consent.

I understand that only I can reach a resolution and that the mediator will not and can not force one upon me. I understand that participation in mediation does not prevent me from using the legal system or other grievance procedures, except as all parties may so agree in writing. I may withdraw from mediation at any time.

I understand and agree that everything said in the mediation session is privileged and confidential and will not be willingly disclosed by the mediator to any other person for any purpose whatsoever.

I understand that any written mediated agreement signed by all parties may be admissible as evidence in any judicial or administrative proceeding.

I agree not to involve our mediator in any legal or contested proceedings whatsoever.

Signature:______________________________

Signature:______________________________

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