Volunteer Mediator Application
Please complete the below form and we will get back to you as soon as possible.
Contact Information
First Name:
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Last Name:
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Email:
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example@example.com
Phone Number:
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Address
City:
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State:
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Postal / Zip code:
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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
Please provide county of residence:
Have you used/gone by any other aliases in the past 7 years?
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Yes
No
Age Range:
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Please Select
17-25
26-35
36-45
46-55
55-65
65m=
Pronouns:
Please Select
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
Work Experience
Resumé:
*
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Headshot (used for Mediator Badge when onboarded):
*
Degree (Check all that apply):
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AA
BA
BS
MD
MFCC
MS
MA
MBA
MA Divinity
JD
CPA
PhD
Other
Occupation:
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Judge
Attorney
Mediator
Pastor
Arbitrator
Business Person
Counselor
CPA
Student
Other
Bar Number:
Professional Affiliations:
SCMA
ACR
NAFCM
AFCC
ICC
IOA
AAA
JAMS
CLS
DRPA Agency
MC3
Other
Mediation Training
Basic mediation training must have been completed within the past seven (7) years. If your initial training extends beyond that, please be sure to provide information on any continuing education (i.e. conference attendance, teaching mediation, specialized training, etc.).
Have you completed a DRPA approved Basic Mediation Training Program (25 hours or more) within the past seven (7) years?
*
Yes
No
Completed via a dispute resolution degree program.
If your Basic Mediation Training was taken over seven (7) years ago, please advise on the year it was taken and any relevant training you have taken since then.
Which institution?
Please Select
Pepperdine University Straus Institute for Dispute Resolution
USC School of Law
Cal State Dominguez Hills
Other
Was your Basic Mediation Training conducted via any of the following providers?
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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)
Other
Please upload your Training Certificate(s).
*
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Mediation Experience
Are you currently active in mediation (court, online, or other)?
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Yes
No
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 in the past three (3) years?
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How many mediations have you performed either in person or online in the past three (3) years?
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Interested Service Areas
Which types of mediations are you interested?
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Small Claims (SC)
Unlawful Detainer (UD)
Civil Harassment (CH) - Temporary Restraining Order
Community Mediation
Would like to learn more.
Locations of Interest:
Antelope Valley Courthouse (SC, CH)
Bellflower (SC)
Beverly Hills (SC)
Chatsworth Courthouse (SC, UD)
Compton Courthouse (SC, UD)
Inglewood Courthouse (SC, UD)
Long Beach Courthouse (SC, UD, CH)
Norwalk (UD)
Pasadena Courthouse (SC, UD, CH)
Van Nuys Courthouse (SC, UD, CH)
West Covina (SC)
Whittier (CH)
Open to Consideration of All/Any
References
1st Reference
*
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
2nd Reference
*
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Submit
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