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 Other option
Occupation
Judge Attorney Mediator Pastor Arbitrator Business Person Counselor CPA Student Other option
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 Other option
How many mediations have you attended or observed?
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) Temporary Restraining Order (TRO) Community Mediation (Before Court Mediation)
Courthouse Preferences:

Alhambra Courthouse (Small Claims) Downey Courthouse (Small Claims) Inglewood Courthouse (Small Claims) Van Nuys Courthouse (Small Claims and Unlawful Detainer) Pomona Courthouse (Restraining Order and UD) All Locations
Time Preference:

AM PM Both
Day(s) Preference

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

Select File

Cancel of
Copy of Training Certificate(s)

Select File

Cancel of
Picture for Mediator Badge
Please list 2 References
Should be Empty: