11th Judicial District ­ District Court REQUEST FOR ADDITION TO PARENTING COORDINATOR LIST Name: Mailing address: Firm: Office Phone: Office Fax: City/State/Zip Code: Email: Directions: Complete and forward the original to Chief District Court Judge, POB 811, Smithfield, NC 27577 Check all that apply: I would like to work in the following 11th Judicial District counties: Harnett Johnston Lee I certify that: (Check all that apply) I hold a masters or doctorate degree in psychology, law, social work, counseling, medicine, or a related subject area. Degree, school, year: I have at least five (5) years of related professional post-degree experience. I hold a current license in my area of practice. Area, Lic. No.: 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. I agree to attend Parenting Coordinator seminars that provide continuing education, group discussion, and peer review and support. I understand that per NCGS §50-93(b), 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 Chief District Court Judge's office informed of any changes in my contact information. I will contact the Chief District Court Judge's 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. Date: Signature: REVIEW BY CHIEF DISTRICT COURT JUDGE Date: Approved Denied Chief District Court Judge Copy mailed to applicant on _________________ by ______________________________________________, TCC. Copy faxed to ________________ County Clerk of Court on ___________, by _________________________, TCC. PC-1 (rev. 10/2014) District 11 ­ Parent Coordinator American LegalNet, Inc. www.FormsWorkFlow.com