CCR VOLUNTEER MEDIATOR APPLICATION

CONTACT INFORMATION
First Name:*
Middle Name / Initial*
Last Name:*
Email:*
Phone Number:*
ADDRESS
Street Address:*
City:*
State:*
Postal / Zip code:*
STREET ADDRESS:
Preferred Address*
CITY:*
STATE:*
ZIP:*
PHONE NUMBER:*
Personal Information
Have you lived outside your current county of residence in the past 7 years?*

YesNo
Have you used/gone by any other aliases in the past 7 years?*

YesNo
Age Range:*
Pronouns:
Which of the following best describes you?*
Languages Spoken (List):
Separate by Semi-Colon
Birth Date:*

MonthDayYear
Education
Degree: (Check all that apply)*

AABABSMDMFCCMSMAMBAMA DivinityJDCPAPhD
Occupation
JudgeAttorneyMediatorPastorArbitratorBusiness PersonCounselorCPAStudent
Bar Number:
Mediation Experience
Are you currently active in mediation (court, online, or other)?*

YesNo
Are you currently active in Court Mediation?

YesNo
Were you active on the LASC Mediation Panel?

YesNo
Were you a panel member as of January 1, 2013?

YesNo
Which panel?

Party Select PanelRandom Select PanelBoth
Which of the following is your area(s) of expertise?*

BusinessCriminalContractsEducationFamilyGeneralPersonal InjuryTortsPatentsPropertyTaxYouthChurch/Religious OrganizationEmployment
How many mediations have you attended or observed either in person or online?*
How many mediations have you performed either in person or online?*
Mediation Training
Total hours of mediation training:*
Please list all mediation classes or training programs and associated dates that you have attended in the past 5 years.
Do you have a training certificate from a Los Angeles County DRP provider?*

YesNo
Which Los Angeles County Dispute Resolution Program (DRP) training(s)did you attend?*

Loyola Law School Center for Conflict ResolutionCenter For Civic MediationAsian-Pacific American Dispute Resolution CenterCalifornia Lawyers for the ArtsCentinela Youth ServicesKorean American CoalitionOffice of the Los Angeles City Attorney, DRPCenter for Conflict Resolution (CCR)
When did you receive the certificate?*

MonthDayYear
Date
Are you currently enrolled as a dispute resolution student?*

YesNo
Which institution?
Are you a graduate of a dispute resolution degree program?

YesNo
Which institution?
Additional Dispute Resolution Training
Interested Service Areas
Which case types are you interested in mediating?*

Small Claims (SC)Unlawful Detainer (UD)Civil Harassment/Temporary Restraining Order (CH)Community Mediation (Before Court Mediation)Would like to learn more.
Are you interested in mediating in person, online, or both?*

I prefer to mediate only in person at the courts.I prefer to mediate only online.I have no preference and would like to learn more.
Locations of Interest:

Antelope Valley Courthouse (SC, UD, CH)Chatsworth Courthouse (SC, UD, CH)Compton Courthouse (SC, UD, CH)Inglewood Courthouse (SC, UD)Long Beach Courthouse (SC, UD, CH)Pasadena Courthouse (SC, UD, CH)Pomona Courthouse (CH)Santa Monica (SC, UD)Torrance (CH)Van Nuys Courthouse (SC, UD, CH)Whittier (CH)Open to Consideration of All/Any
Time Preference:

AMPM
Day(s) Preference

MondayTuesdayWednesdayThursdayFriday
Professional Affiliations
SCMAACRNAFCMAFCCICCIOAAAAJAMSCLSDRPA AgencyMC3
Resumé*

Select File

Cancelof
Copy of Training Certificate(s)*

Select File

Cancelof
Picture for Mediator Badge*
Reference 1
References
1st Reference*

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
2nd Reference*

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Should be Empty: