MARIN COUNTY SUPERIOR COURT 3501 Civic Center Drive, Room 113 P.O. Box 4988 San Rafael, CA 94913-4988 Application to Serve as Volunteer Settlement Conference Panelist for Civil Family Law Attorney Mental Health Professional 1. Contact Information Name: Business address: City: Mailing address (if different): Work No.: Fax No.: Home No.: Email Address: Cell No.: State: Zip: CA Professional Lic. No.: 2. Professional and Personal Qualifications Date of admission to the State Bar of California or date of Ph.D., MFT or LCSW licensure: Are you a party to any pending criminal, civil, small claims, family law or probate proceeding in this court? Yes No (If you answered yes, please explain in a separate attachment.) If applying as a Civil Settlement Conference Panelist, have you met the qualifications described in California Rule of Court Yes No 10.781 for court-related ADR neutrals? 3. Practical Experience Business (Commercial/Contract) Family Law Labor - Employment Legal Malpractice Other: % % % % Yes Yes Yes Yes No No No No Medical Malpractice Personal Injury Probate Real Estate % % % % Yes Yes Yes Yes No No No No PLEASE SEE GUIDELINES ON PAGE 2 I understand and acknowledge that serving as a volunteer settlement conference panelist is solely at the discretion of the court for the purpose of assisting the public and does not constitute an employment relationship. I am aware of and will comply with all provisions of the California Rules of Court concerning court related ADR neutrals. If I am, or the firm/practice group in which I am an equity partner is, a party to any pending or impending litigation in the court, I understand that I cannot serve as a volunteer settlement conference panelist until such cases have been disposed. If asked to serve as a volunteer settlement conference panelist while I have cases pending, I agree to decline the appointment and notify the court. This does not apply to instances where I represent or am treating parties with pending or impending actions before the court. I declare under penalty of perjury under the laws of the State of California that the foregoing, including statements made in all attachments, is true and correct. I understand that any misstatement or omission of material fact may disqualify me from serving as a volunteer family law settlement conference panelist in this court. DATE CV055 / FL055 (Rev. 11/15) APPLICANT'S SIGNATURE APPLICATION TO SERVE AS VOLUNTEER SETTLEMENT CONFERENCE PANELIST CIVIL OR FAMILY LAW Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com QUALIFICATION GUIDELINES FOR PARTICIPATING AS A FAMILY LAW SETTLEMENT CONFERENCE PANELIST Attorneys: The court suggests that participants have the following knowledge, experience or training: Experience in litigation and/or the settlement of custody cases through mediation or the collaborative process, involving a significant number of high conflict custody disputes Domestic Violence and the differentiation of types of domestic violence Child Abuse, Alcohol and Substance abuse Appointments as Minor's Counsel Age-appropriate parenting arrangements for divorced families Impact of entrenched parental conflict on child adjustment Impact of step-parents and blended families on parenting relationships Mental Health Professionals: The court suggests that participants have the following knowledge, experience or training: Mental Health Professional licensed in California Experience working with divorcing families, as well as experience in providing services to parents and children in high conflict families Mediation/collaborative training and/or experience and negotiation skills Basic knowledge of Family Law and the Family Law Court system Familiarity with domestic violence, alcohol and substance abuse and potential impact on appropriate post-divorce arrangements Familiarity with research on impact of divorce on children and families The range of age-appropriate time-share and parenting arrangements for divorced families Impact of separation and divorce on parents, children, parent-child relationships and quality of parenting and family dynamics Indicators of child abuse and neglect and knowledge of related reporting laws CV055 / FL055 (Rev. 11/15) APPLICATION TO SERVE AS VOLUNTEER SETTLEMENT CONFERENCE PANELIST CIVIL OR FAMILY LAW Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com