Pag e 1 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster IDAHO SUPREME COURT 451 WEST STATE STREET P.O. BOX 83720 BOISE, IDAHO 83720-0101 APPLICATION FOR REGISTRATION AS A PARENTING COORDINATOR IN PARENTING DISPUTES (I.R.F.L.P. 716 ) Part 1 General Information 1. Registration: Qualifications of Parenting Coordinators A. To be placed on the Supreme Court's list of parenting coordinators, the applicant must be an attorney, a licensed psychologist or counselor, a licensed clinical social worker, licensed master social worker - independent practice, school counselor, or school psychologist. The applicant must also be on the current list of child custody mediators complied by the Idaho Supreme Court pursuant to Rule 602, I.R.F.L.P . In addition, the applicant must have attended at least twenty (20) hours of training in domestic violence and lethality assessment as evidenced by the attached certificate(s) of completion or other supporting documentation. An applicant must have a basic familiarity with child development as it pertains to issues of bonding, attachment, loss in early life, and future child development, as evidenced by college coursework, classes, workshops, or training as stated in an attached certificate of completion or other supporting documentation. Each applicant must also successfully complete a current criminal history check. In addition, the applicant must be familiar with Rule 716, I.R.F.L.P ., enclosed with this application. B. Parenting Coordinators are expected to maintain statistical records and evaluation outcomes for purposes of quality control and to provide information as required by the Idaho Supreme Court for submission to the Idaho Legislature. C. To remain on the Supreme Court List of Parenting Coordinators, an applicant must remain on the list of child custody mediators compiled by the Idaho Supreme Court. In addition, applicant must complete an updated criminal history check every five (5) years pursuant to Rule 47, I.C.A.R .: Criminal History Checks. 2. Criminal History Check A. Applicant must submit to a current criminal history check, at his or her own expense, as provided for in Rule 47, I.C.A.R . The criminal history check will consist of a self-declaration, fingerprints of the individual, information obtained from a national records check conducted by the Idaho Bureau of Criminal Identification, the Federal Bureau of Investigation, the statewide Child Abuse Registry, Adult Protection Registry, and the Sexual Offender Registry. Results of the criminal history check will be mailed to the Idaho Supreme Court. For a list of crimes resulting in unconditional denial, please see Rule 47 . All other crimes will result in conditional denial. American LegalNet, Inc. www.FormsWorkFlow.com Pag e 2 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster Fingerprinting is provided by some law enforcement agencies. Applicants who reside in Ada County are required to have fingerprinting done at the Idaho State Police offices located at 700 S. Stratford Drive, Meridian, Idaho. Applicants outside the Ada County area may contact their local sheriff's office to arrange for having the fingerprinting done, or you may contact the Idaho State Police (208-884-7130) for a list of agencies in your area who provide fingerprinting. Fees may range from $3.00 to $10.00. Applicants may obtain a fingerprint card by contacting Susan Wendt, Judicial Administrative Assistant at the Idaho Supreme Court, at (208) 947-7456 or via e-mail at: swendt@idcourts.net. The fingerprint card, together with a money order for $37.00 payable to the Idaho Supreme Court should be included with the remaining Supporting Documentation, listed below. 3. Supporting Documentation An applicant must submit the following to be placed on the list of parenting coordinators maintained by the Supreme Court: A. The attached Application; B. An Affidavit of Compliance executed by the applicant attesting that the applicant has fulfilled the requirements for registration; C. A Self-Declaration signed by the applicant under penalty of perjury attesting to any felony or misdemeanor convictions or pending criminal charges; D. FBI Noncriminal Justice Applicant Privacy Statement, signed and dated; E. Notarized Authorization to Investigate and Authorization and Consent to Release Information forms; F. Idaho State Police Criminal History Record Checks under the National Child Protection Act of 1993, as amended; and G. A Fingerprint Card and Money Order for $37.00, as outlined above. 4. All of these documents should be mailed to: Idaho Supreme Court Attn: Susan Wendt P.O. Box 83720 Boise, ID 83720-0101 Telephone: (208) 947-7456 [PLEASE SEE CHECKLIST AT END OF APPLICATION] American LegalNet, Inc. www.FormsWorkFlow.com Pag e 3 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster Idaho Supreme Court APPLICATION FOR REGISTRATION AS A PARENTING COORDINATOR (Rule 716, I.R.F.L.P.) Name: Organization: Mailing Address: City: County: State: Zip: Telephone: Fax: E-Mail Address: Note that the information you furnish above will be used in all correspondence with you and on the public roster of mediators. I herewith apply for registration on the list of parenting coordinators maintained by the Idaho Supreme Court pursuant to Rule 716 I.R.F.L.P. In support of this application, I state the following: I am licensed or certified as a by the state of (Attach a copy of current professional license or certificate.) I am currently registered on the Idaho Supreme Court List of Child Custody Mediators. I have read and am familiar with Rule 716: Appointment of Parenting Coordinator in Child Custody and Visitation Disputes. I have read and am familiar with Rule 47, I.C.A.R.: Criminal History Checks. I agree to maintain statistical records and evaluation outcomes for purposes of quality control and to provide information as required by the Idaho Supreme Court for submission to the Idaho Legislature. American LegalNet, Inc. www.FormsWorkFlow.com Pag e 4 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster I submit the following information for inclusion on the Supreme Court's roster of parenting coordinators. (Please attached extra pages, as needed, to complete the information. (1) I have participated i n a minimum of twenty (20) hours of training in domestic violence, violence in families, child abuse, anger management, lethality assessments, and psychiatric causes of violence, as evidenced by the attached certificate(s) of completion or other supporting documentation, and the following information: Sponsor: Location: Date(s): Hours: Course Content: Sponsor: Location: Date(s): Hours: Course Content: (2) I have basic knowledge of child development as it pertains to bonding and attachment, loss in early life and future child development as evidenced by the following: (list college coursework, workshops, training or professional experience. If using professional experience, describe your area of practice and length of experience. Please attach supporting documentation. Course Content: Course Content: American LegalNet, Inc. www.FormsWorkFlow.com Pag e 5 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster (3 ) Professional Affiliations: (bar organizations, alternative dispute resolution organizations, etc. ) Organization: Address: Type of Membership: Membership Expires: Organization: Address: Type of Membership: Membership Expires: (4 ) Academic and Professional Education and Training: ( 5 ) Professional Experience: I nclude professional experience i n the area of domestic violence. a) Describe your areas of practice or specialty: b) Describe your alternative dispute resolution experience: c) Describe any other professional experience you have that is pertinent to your ability as a parenting coordinator, e.g. work with divorcing parents, work with children, etc. American LegalNet, Inc. www.FormsWorkFlow.com Pag e 6 Applicatio n for Registration on the Idaho Suprem e Court's Parentin g Coordinator Roster (6) My hourly rate of c