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Application For Mediator Certification ADR-1000A - Virginia
| Application For Mediator Certification Form. This is a Virginia form and can be used in ADR Supreme Court Statewide . |
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OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA APPLICATION FOR MEDIATOR CERTIFICATION Please use black ink so this document will be legible when scanned. This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, political affiliation, national origin, disability, sex or age. SECTION I 1. Name: GENERAL INFORMATION Last Please type or print. First Middle Business Name (if different from above): Primary Address: Street and/or Post Office Box City 2. Last 4 Digits Social Security Number: Home Phone: E-mail: 3. Website: Degree(s) Attained State Office Phone: Fax: Zip Code County Colleges, Universities, and Graduate Schools Attended: Dates Attended City/State From Name To Major 4. Are you already currently certified as a mediator for a different category of cases? Yes If yes, in what category? GDC JDR CCC CCF If yes, you do not need to fill in #5 below if you have no bachelor's degree. No 5. If you have not received a bachelor's degree, please attach a letter describing your relevant work and life experience and qualifications sufficient to support certification, such as specific business or military experience or experience in the field of dispute resolution. The letter must be accompanied by a resume and two letters of recommendation that address your oral and written communication skills. Additional information may be requested. (You should seek a waiver prior to beginning mediation training.) I have a bachelor's degree. Yes No (If no bachelor's degree, letter, resume & letters of recommendation must be attached) July 2011 FORM ADR-1000A 1 American LegalNet, Inc. www.FormsWorkFlow.com 6. Please list all professional affiliations that you consider relevant to your certification. 7. Please check the type(s) of certification for which you are applying: General District Court Juvenile and Domestic Relations District Court Circuit Court-Civil Circuit Court-Family SECTION II CERTIFIED TRAINING (If you have taken a mediation training out of state, you may request a waiver for the analogous Virginia certified training from Dispute Resolution Services. You should request a waiver prior to beginning any other training. If you have received a waiver, please attach documentation of the waiver to this application.) 1. General District Court Mediation (Minimum 20 hours: 20-hr basic) List the certified mediation training you have received. Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. Course/Hours Trainer Location Date 2. Juvenile and Domestic Relations District Court Mediation (Minimum 40 hours: 20-hr basic and 20-hr family) List the certified mediation training you have received. Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. Course/Hours Trainer Location Date 3. Circuit Court-Civil Mediation Training (Minimum 40 hours: 20-hr basic and 20-hr circuit court civil) List the certified mediation training you have received. Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. Course/Hours Trainer Location Date 4. Circuit Court-Family Mediation Training (Minimum 52 hours: 20-hr basic, 20-hr family, and 12-hr circuit court family) List the certified mediation training you have received. Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. July 2011 FORM ADR-1000A 2 American LegalNet, Inc. www.FormsWorkFlow.com Course/Hours Trainer Location Date SECTION III TRAINING IN SCREENING FOR DOMESTIC ABUSE (required for Juvenile and Domestic Relations District Court and Circuit Court-Family Mediators) (Minimum 8 hours) 1. Describe the certified training you have received in screening for and dealing with domestic abuse in the mediation context. Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. Course/Hours Trainer TRAINING IN VIRGINIA'S JUDICIAL SYSTEM Location Date SECTION IV 1. Describe the certified training or experience you have received in Virginia's judicial system. (Minimum 4 hours) Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. If you are a member in good standing of the Virginia State Bar, please provide your bar number. Course/Hours Trainer OBSERVATIONS AND CO-MEDIATIONS Location Date SECTION V 1. a. Observations: Attach Forms ADR-1007 (Verification of Observation) from qualified Mentors attesting to your observations. Please see Section C.3. of the Guidelines for number of observations required. Case Type: General District, J&DR, Circuit-Civil or Circuit-Family Date(s) of Observation Name of Mentor or b. Certified Observation Course: Form ADR-1006 (Trainee Evaluation Form) is required from the trainer. Course/Hours Trainer Location Date 2. Co-Mediations: Attach Forms ADR-1001 (Mentee Evaluation Form) which must be completed by qualified Mentors and Form ADR-1008 (Mentee Portfolio Form) completed by both Mentors and Mentee. Please see Section C.3.of the Guidelines for type and number of co-mediations required. Case Type: General District, J&DR, Dates of Circuit-Civil or Circuit-Family Co-mediations Hours of Mediation Name of Mentor July 2011 FORM ADR-1000A 3 American LegalNet, Inc. www.FormsWorkFlow.com 3. Please enclose a written Memorandum of Agreement/Understanding written by you (for which you served as primary scrivener) for each level of certification you are seeking. Date of Mediation: Date of Mediation: Mentor: Mentor: 4. If you are seeking Juvenile and Domestic Relations District Court or Circuit Court-Family certification, please enclose a child support worksheet completed by you, by hand, using a calculator and the statute. Date of Mediation: Mentor: SECTION VI 1. RECIPROCITY (If you are currently practicing mediation in another state, please complete this Section.) Please provide evidence of mediation training. Attach copies of outlines, agendas, and letters or certificates of successful completion. Course/Hours Trainer Location Date 2. Please provide evidence of successful completion of four hours of training in Virginia's judicial system. Form ADR-1006 (Trainee Evaluation Form) completed by the trainer is required. Course/Hours Trainer Location Date 3. Please provide evidence of at least two hours of education on Virginia's Standards of Ethics for certified mediators. Form ADR-1006 (Trainee Evaluation Form) completed by the trainer is required. Course/Hours Trainer Location 4. If you are seeking Juvenile and Domestic Relations District Court or Circuit Co
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