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
*
Please Select
HOME
WORK
CITY:
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STATE:
*
ZIP:
*
PHONE NUMBER:
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Personal Information
Have you lived outside your current county of residence in the past 7 years?
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Yes
No
Have you used/gone by any other aliases in the past 7 years?
*
Yes
No
Age Range:
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17-25
26-35
36-45
46-55
55-65
65m=
Pronouns:
She/Her/Hers
He/Him/His
They/Them/Theirs
Other
Which of the following best describes you?
*
Please Select
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Heritage
White or Caucasian
Multiracial or Biracial
A race/ethnicity not listed here
Languages Spoken (List):
Separate by Semi-Colon
Birth Date:
*
-
Month
-
Day
Year
Education
Degree: (Check all that apply)
*
AA
BA
BS
MD
MFCC
MS
MA
MBA
MA Divinity
JD
CPA
PhD
Other
Occupation
Judge
Attorney
Mediator
Pastor
Arbitrator
Business Person
Counselor
CPA
Student
Other
Bar Number:
Mediation Experience
Are you currently active in mediation (court, online, or other)?
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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
Other
How many mediations have you attended or observed either in person or online?
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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?
*
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
Center for Conflict Resolution (CCR)
When did you receive the certificate?
*
-
Month
-
Day
Year
Date
Are you currently enrolled as a dispute resolution student?
*
Yes
No
Which institution?
Please Select
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?
Please Select
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
Which case types are you interested in mediating?
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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)
Compton Courthouse (SC, UD)
Inglewood Courthouse (SC, UD)
Long Beach Courthouse (SC, UD, CH)
Pasadena Courthouse (SC, UD, CH)
Santa Monica (SC, UD)
Van Nuys Courthouse (SC, UD, CH)
Whittier (CH)
Open to Consideration of All/Any
Time Preference:
AM
PM
Day(s) Preference
Monday
Tuesday
Wednesday
Thursday
Friday
Professional Affiliations
SCMA
ACR
NAFCM
AFCC
ICC
IOA
AAA
JAMS
CLS
DRPA Agency
MC3
Other
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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