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A.R. Rucker Peer Mediation Referral Form
All completed forms will be emailed directly to Ms. Sydney
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* Indicates required question
Email
*
Your email
Student #1 (Name and Grade)
*
Your answer
Student #2 (Name and Grade)
Your answer
Person Making Request:
*
School Administration
Teacher
Student
Other:
Required
Place of Conflict:
*
On Campus
Off Campus
Required
Type of Conflict:
*
Your answer
Mediation:
Immediate Mediation
Scheduled Mediation
Mediation Scheduled Date:
MM
/
DD
/
YYYY
Mediation Scheduled Time:
Time
:
AM
PM
All recorded responses are confidential
If you have any questions or concerns, feel free to reach out via email
sydney.gordon@lcsd.k12.sc.us
or stop by my office at room 202 on Wednesdays and Fridays
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