Approved, SCAO DOMESTIC RELATIONS MEDIATOR APPLICATION To be eligible to serve as a domestic relations mediator, you must meet the training and experience criteria specified either in MCR 3.216(G) or in the SCAO Mediation Training Standards and Procedures under MCR 3.216(G)(2). Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Refer to the Mediation Training Standards and Procedures for further information about minimum qualifications. Note: Except for Part B, the information provided in this application is available to the public for inspection. Please type or print neatly. 1. Full name (first, middle initial, last) 2. Bar no. if applicable P 3. Address where you can be contacted 4. Telephone no. 5. Fax no. ( ( ) 6. E-mail address ) Part A: Domestic Relations Mediator Qualifications Complete items 7 and 8, and either item 9, 10, or 11 as appropriate. 7. Is this a new application? renewal? If renewing, complete item 11 and attach a copy of your original application. 8. Completed a 4-hour domestic violence program approved by the State Court Administrative Office on 9. Qualification through State Court Administrative Office (SCAO)-Approved Training / Association for Conflict Resolution (ACR) Training a. SCAO/ACR-approved training completed on . Date . Date Attach copy of certificate. Trainer: If ACR training was completed more than 2 years before applying, the applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. b. Licensed in appropriate field. Specify. Master or graduate degree in appropriate field. 5-years' experience in family counseling. Attach copy of diploma. Detail below. Complete on separate page if needed. c. Observed two domestic relations mediation proceedings. Specify dates and mediator names and attach verification. Do not include party names. d. Conducted one domestic relations mediation to conclusion. Specify date and name of mediator serving as supervisor and attach verification. Do not provide party names. continued on page 2 DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 1 of 4 MC 281b (3/09) MCR 3.216(G) American LegalNet, Inc. www.FormsWorkFlow.com Domestic Relations Mediator Application, continued from page 1 Part A: Domestic Relations Mediator Qualifications (continued) 9. e. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. f. As a non-Michigan licensed lawyer/nonlawyer, I completed on , Date a 6-hour program addressing basic Michigan laws, rules, and guidelines governing domestic relations actions. Instructor: 10. Qualification by Training and Experience Comparable to ACR-Approved Training a. Completed a training course of at least 24 hours including participation in mediation and at least 25% role play by December 31, 2000. Attached are: (1) a certificate of completed training, (2) a copy of the training agenda, (3) the name of the trainer, (4) the date of the training, and (5) the dates of attendance. Training included the following core elements: Check appropriate boxes. experience of divorce for adults and children family law and family economics information gathering skills and knowledge relationship skills and knowledge communication skills and knowledge problem-solving skills and knowledge professional skills and knowledge mediation, negotiation, and conflict management theory and skills ethical decision-making and values skills and knowledge If the training was completed more than 2 years before applying, applicant must have completed at least 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. b. Licensed in appropriate field. Specify. Master's or graduate degree in appropriate field. 5-years' experience in family counseling. Attach copy of diploma. Detail below. Complete on separate page if needed. continued on page 3 MC 281b (3/09) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 2 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkFlow.com Domestic Relations Mediator Application, continued from page 2 Part A: Domestic Relations Mediator Qualifications (continued) 10. c. Mediated or comediated at least 40 hours or 10 domestic relations cases in the 2 years before this application. Detail below. Complete on separate page if needed. Do not provide party names. d. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. e. As a non-Michigan licensed lawyer/nonlawyer, I completed on , Date a 6-hour program addressing basic Michigan laws, rules, and guidelines governing domestic relations actions. Instructor: 11. Renewing Application If the mediation training was completed more than 2 years before applying, applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and names of trainers, and attach copy of certificate. CERTIFICATION I certify that I: (a) meet the requirements for service under the court's mediator selection plan; (b) will not discriminate against parties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and (c) will comply with the court's ADR plan, orders of the court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court Administrator. My hourly fee is $ Date MC 281b (3/09) . Signature DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 3 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkFlow.com Domestic Relations Mediator Application - gender and race information to be maintained separately from pages 1 - 3 of application Full name (first, middle initial, last) (print or type) Bar no. (if applicable) P Part B: Gender and Race Information Providing the following information is optional. It is requested in accordance with MCR 3.216(F)(1)(c) and will be maintained separately from your application. Check the boxes that apply to you. Gender: Female Male Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): Part C: Pro Bono and Observee/Observer Information Providing the following information is optional and will be maintained separately from your application. 1. Once you have been qualified by the court to serve as a mediator: a. Are you willing to be observed by a prospective mediator? No b. Are you willing to observe a prospective mediator in mediation pro bono? 2. Yes Yes No Are you willing to accept appointment from the court to serve as a pro bono mediator once a year? Yes No MC 281b (3/09) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 4 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkFlow.com