CCR VOLUNTEER MEDIATOR
APPLICATION
CONTACT INFORMATION
FIRST NAME:
*
LAST NAME:
*
PREFERED EMAIL:
*
PREFERED ADDRESS
*
HOME
WORK
Home
STREET ADDRESS:
*
CITY:
*
STATE:
*
ZIP:
*
PHONE NUMBER:
*
Work
STREET ADDRESS:
*
CITY:
*
STATE:
*
ZIP:
*
PHONE NUMBER:
*
Personal Information
Gender:
*
Male
Female
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?
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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?
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Yes
No
Which Los Angeles County Dispute Resolution Program (DRP) training(s)did you attend?
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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?
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-
Month
-
Day
Year
Date
Are you a currently enrolled dispute resolution student?
*
Yes
No
Which institution?
Pepperdine University Straus Institute for Dispute Resolution
USC School of Law
Cal State Dominguez Hills
Other
Are you a graduate of a dispute resolution degree program?
Yes
No
Which institution?
Pepperdine University Straus Institute for Dispute Resolution
CSUN Mediation and Conflict Resolution Certificate Program
UCLA Law School
USC Law School
CSUDH - Master Degree Program
Other
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
Submit
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