CCR VOLUNTEER MEDIATOR APPLICATION

CONTACT INFORMATION
FIRST NAME: *
LAST NAME: *
PREFERED EMAIL: *
PREFERED ADDRESS *
Home
STREET ADDRESS: *
CITY: *
STATE: *
ZIP: *
PHONE NUMBER: *
Work
STREET ADDRESS: *
CITY: *
STATE: *
ZIP: *
PHONE NUMBER: *
Personal Information
Gender: *
Birth Date: *

Month Day Year
Date
Ethnicity *
Education
Degree: (Check all that apply) *

AA BA BS MD MFCC MS MA MBA MA Divinity JD CPA PhD
Occupation
Judge Attorney Mediator Pastor Arbitrator Business Person Counselor CPA Student
Bar Number:
Mediation Experience
Are you currently active in mediation? *

Yes No
Are you currently active in Court Mediation? *

Yes No
Were you active on the LASC Mediation Panel?

Yes No
Were you a panel member as of January 1, 2013?

Yes No
Which panel?

Party Select Panel Random Select Panel Both
Which of the following is your area(s) of expertise? *

Business Criminal Contracts Education Family General Personal Injury Torts Patents Property Tax Youth Church/Religious Organization Employment
How many mediations have you attended or observed?
How many mediations have you performed?
Mediation Training
Total hours of mediation training? *
Last class or mediation training program attended?
Do you have a training certificate from a Los Angeles County DRP provider? *

Yes No
Which Los Angeles County Dispute Resolution Program (DRP) training(s)did you attend? *

Loyola Law School Center for Conflict Resolution Center For Civic Mediation Asian-Pacific American Dispute Resolution Center California Lawyers for the Arts Centinela Youth Services Korean American Coalition Office of the Los Angeles City Attorney, DRP California Academy of Mediation Professionals Center for Conflict Resolution (CCR)
When did you receive the certificate? *

Month Day Year
Date
Are you a currently enrolled dispute resolution student? *

Yes No
Which institution?
Are you a graduate of a dispute resolution degree program?

Yes No
Which institution?
Additional Dispute Resolution Training
Interested Service Areas
Case Type:

Small Claims (SC) Unlawful Detainer (UD) Civil Harassment/Temporary Restraining Order (CH) Community Mediation (Before Court Mediation)
Courthouse Preferences:

Antelope Valley Courthouse (Small Claims, Unlawful Detainer, Civil Harassment) Bellflower Courthouse (SC) Chatsworth Courthouse (SC, UD, CH) Compton Courthouse (SC, UD, CH) Inglewood Courthouse (SC, UD) Pasadena Courthouse (SC, UD, CH) Pomona Courthouse (CH) Santa Monica (SC, UD) Van Nuys Courthouse (SC, UD, CH) West Covina Courthouse (SC,UD) All Locations Long Beach Courthouse (SC, UD, CH)
Time Preference:

AM
Day(s) Preference

Monday Tuesday Wednesday Thursday Friday
Professional Affiliations
SCMA ACR NAFCM AFCC ICC IOA AAA JAMS CLS DRPA Agency MC3
Resumé *

Select File

Cancel of
Copy of Training Certificate(s) *

Select File

Cancel of
Picture for Mediator Badge *
Reference 1
References
1st Reference *

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
2nd Reference *

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Should be Empty: