Volunteer Mediator Application

Thanks for you interest in the Early Settlement mediation program. The program is funded by the Supreme Court of Oklahoma and utilizes volunteers who have been trained and certified by the Administrative Director of the Court. The initial basic training is a 20-hour course provided at no charge to volunteer applicants who agree to give 10 hours of volunteer service back to the program each year.

Upon completion of the training you will be scheduled to observe a certified mediator conducting a small claims case or something similar, and then be obeserved mediating a case to be considered for certification.

Additional information about Early Settlement is available at https://adrs.oscn.net/

If you have questions about how to properly complete this form please contact our office at 405-295-6180

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email (Note: most communication from our office will be via email).

example@example.com

Phone Number

Please enter a valid phone number.

Occupation (If college student please notate here)

If you are a licensed attorney, please enter your OBA#

How did you learn about Early Settlement Mediation? (Please select all answers that are applicable)

What do you expect to gain from this training/experience?

Have you previously applied for training with any other Early Settlement program?

YesNo

If Yes, Please list Early Settlement Program Name Below and Date of Application

	Early Settlement Program Name	Date of Application

Have you received any previous mediation or communication training as well as other forms of Alternative Dispute Resolution (ADR) training?

YesNo

If Yes, Please list the training information below

	Description of Training	Provided by	Number of Hours	Date M/YR
Training 1
Training 2
Training 3

Are you currently, or have you been involved with volunteer activities in the past?

YesNo

If yes, Please list past and present volunteer activities with which you have been involved with:

	Organization Name	Description of Volunteer Activity	Start Date (M/YR)	End Date (M/YR)
Activity 1
Activity 2
Activity 3

Have you been convicted of a felony within the past 5 years?

If yes, Please explain below:

Do you have a reliable form of transportation?

YesNo

Do you speak any languages other than English?

If yes, please list additional languages

In this next section we want to learn about your experience.

Please list (3) references who know you and your work from both paid or volunteer work settings and/or educational settings. Do not list relatives as references. In providing us with these references, you accept that our discussion with your references are confidential. This is important to assure complete candor.

	Name:	Email Address	Phone	Relationship
Reference 1
Reference 2
Reference 3

Are you currently a college, or university student?

YesNo

If Yes, please tell us what college or university you attend and your major/ field of specialization, date of graduation, and do you plan to reside in Oklahoma following graduation?

	Name	Major/Field of specialization	Date of Graduation	Do you plan to reside in OK following graduation?
College/ University

Please mark, or check, each statement acknowledging that you have read it and are in agreement with the statement:

I can commit to two (2) or more years of volunteer service following certification with a minimum of 10 hours per year to the Early Settlement Mediation Program.I can mediate in small claims court or perform office related tasks, such as follow-up surveys monthly.I understand that I will NOT be monetarily compensated for mediation services nor reimbursed for expenses incurred with mediating for Early Settlement Mediation (if applicable, parking fees may be reimbursed).I can refrain from giving advice and/or my opinion in order to permit the parties to create their own resolutions to disputes.I can encourage the parties to reach their own mutually negotiated solution(s).I can follow a specific script made to conduct mediationI UNDERSTAND THAT COVERAGE OF MEDIATORS UNDER THE OKLAHOMA DISPUTE RESOLUTION ACT (I.E. CONFIDENTIALITY, LIABILITY PRIVILEGE, ETC.) IS AFFORDED ONLY TO THOSE WHO ARE MEDIATING FOR EARLY SETTLEMENT WHEN THEY ARE ACTING AS VOLUNTEERS. People who mediate as private practitioners, or for a fee are not in anyway protected by the Dispute Resolution Act and cannot claim state certification.I understand that Early Settlement provides a valuable community service of which I will be an important and integral part.I understand that the training workshop is offered to me at no cost, provided that I render the equivalent of two (2) or more years of volunteer service to the community through the Early Settlement Mediation Program.

Why do you want to volunteer as an Early Settlement Mediator?

Please indicate what times you would be available to mediate for Early Settlement

Please select the locations you would be able to mediate for Early Settlement:

Signature By signing below you acknowledge that you have read and agree to the above statements and have answered all questions as truthfully as possible.

The signature box is SENSITIVE! Please check that your signature is complete before hitting the submit button.

Date of Signature:

Date

Supreme Court of Oklahoma

Alternative Dispute Resolution System

VOLUNTEER MEDIATOR CANDIDATE AGREEMENT

On this number day of month 20 year , I, First Name, upon having been interviewed by the program director, understand that I have just completed the first, in a series of volunteer qualifying events for the area mediation program. The next step in the series is the satisfactory completion of a 20-hour introductory mediation training program. My satisfactory completion will be based on evaluations by the local program director with input from the training program facilitator, group leader and coach. The evaluation is focused on my understanding of the mediation process as demonstrated through performance. I understand that this training will qualify me to move on to the next phase of certification as a mediator pursuant to the provisions of the Dispute Resolution Act, 12 O.S. Supp. 1991 sections 1801 et seq., and I will be notified by the local program director or coordinator of my additional certification requirements including, at a minimum, observing a mediation conducted by an certified mediator and being observed while conducting a mediation.

Upon attaining certification as a mediator pursuant to the provisions of the Act, I agree to provide a minimum of 10 hours per year of service to the certified programs of the Oklahoma Alternative Dispute Resolution System (ADRS). If I choose not to continue in this process, I will notify the local program director, or coordinator, in writing, of my intent to discontinue participation in the mediation program.

I understand that the Act (i.e. certification, confidentiality, liability, privilege, etc.) is applicable to me only when I am mediating for a certified program of the Oklahoma ADR System and am acting as a volunteer. I will not claim, advertise or assert that I am certified as a mediator except in reference to my volunteering under the authority of a certified program of the Oklahoma ADR System.

I UNDERSTAND THAT I MAY BE RELEASED, AT ANY TIME, FROM DUTIES AND RESPONSBILITIES AS A CANDIDATE AND/OR CERTIFIED MEDIATOR, BY THE LOCAL PROGRAM DIRECTOR OR COORDINATOR, OR THE MEDIATION TRAINER. I UNDERSTAND THAT IF I OBTAIN CERTIFICATION IT WILL EXPIRE ONE (1) YEAR FROMT HE DATE OF CERTIFICATION, UNLESS EXTENDED BY THE ADMINISTRATIVE DIRECTOR OF THE COURTS. IF I LOSE MY CERTIFICATION, I UNDERSTAND THAT ANY REFERENCE I MAKE TO IT MUST LIST THE DATES BETWEEN WHICH IT WAS VALID.

Thank you for completing our Volunteer Mediator Application. Our office will be in touch soon!

Volunteer Mediator Candidate Signature:

The Signature Box is very SENSITIVE! Please check that your signature is complete before hitting the submit button.

Date of Signature

Date