DUR-DOM-22 (Rev. 6/17) Page 1 of 2 Request for Inclusion on the Parenting Coordinator List Name: Practice/Firm Name: Address: Phone: Fax: Email: THIS SECTION MUST BE COMPLETED FOR INCLUSION I certify the following: (Check all that apply) I hold a masters or doctorate degree in psychology, law, social work, counseling, medicine, or a related subject area. Degree (specify in which area): University/College: Year Obtained: I have at least five years of related professional post-degree experience. I hold a current license in my area of practice. Area of Practice: License Number: Not Applicable (list why): I have attached a copy of my current resume or curriculum vitae. I have completed 24 hours of training in topics related to the developmental stages of children, the dynamics of high-conflict families, the stages and effects of divorce, problem solving techniques, mediation, and legal issues. I have attached documentation that clearly indicates that the above 24 hours of training requirement has been satisfied (e.g. list the trainings, dates, hours, and locations). I agree to attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support. I understand, that per HB Section 50-93, I must attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support to remain eligible to serve as a Parenting Coordinator. I will keep the Family Court Office informed of any changes in my contact information. I will provide the Family Court Administrator with information on my parenting coordination fee schedule, including any rate changes. American LegalNet, Inc. www.FormsWorkFlow.com DUR-DOM-22 (Rev. 6/17) Page 2 of 2 I will contact the Family Court Office if I become ineligible to continue to serve as a Parenting Coordinator. I understand that the Chief District Court Judge will remove my name from the Parenting Coordinator List if I become ineligible to continue to serve as a Parenting Coordinator. This the day of , 20. (Signature) For use by the District Court Judges222 Office Only: Request for Inclusion on the Parenting Coordinator List Approved Denied: Chief District Court Judge (or designee) Date: American LegalNet, Inc. www.FormsWorkFlow.com