OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA APPLICATION FOR MEDIATION COURSE CERTIFICATION Please use black ink so this document will be legible when scanned. Applications for course certification must be submitted at least thirty (30) days in advance of the training date. DRS will review applications within thirty (30) calendar days of receipt. Please note that extra time should be allotted beyond the thirty (30) days for the applicant to make any changes/revisions that may be necessary. This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, religion, political affiliation, national origin, handicap, sex or age. SECTION I PROGRAM INFORMATION (Please type or print.) 1. Name and mailing address of person responsible for the training program: 2. This application is for certification of a: a. b. c. d. e. f. 20-Hr. Basic g. 4-Hr. VA Judicial 20-Hr. Family h. 8-Hr. Domestic Abuse 40-Hr. Family i. 4-Hr. Mentoring Others 20-Hr.Circuit-Civil j. 8-Hr. Observation (Class is for: 12-Hr.Circuit-Family GDC J&DR CCC CCF certification Other (Specify number of hours and subject matter) 3. Name(s), mediator certification number(s), certification type(s), and last recertification date of trainer(s) seeking certification. [Attach resume(s)] 4. Mediation training of trainer(s) seeking certification. 5. Education of trainer(s) seeking certification. FORM ADR-2000 July 2011 1 American LegalNet, Inc. www.FormsWorkFlow.com 6. Mediation experience of trainer(s) seeking certification. 7. Adult Education experience of trainer(s) seeking certification. 8. Has the training program been presented before? Yes No If so: a. Number of times this training program has been presented b. Number of participants in most recent presentation c. Attach evaluations of the program by the participants in the most recent presentation. 9. a. Minimum number of participants for this course b. Maximum number of participants for this course 10. Number of experienced mediators who will observe, process, and critique the role plays Ratio of trainees to observers Names and certification level of observers. If not, describe method of selection for the observers.) 11. Names and certification level of training assistants 12. Name and experience of subject matter specialists SECTION II GENERAL COURSE INFORMATION 1. Please describe the objectives of the training program FORM ADR-2000 July 2011 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. Please describe the format of the program and give approximate time spent on the following: lecture, discussion, exercises, and role plays 3. Please attach a copy of the course agenda, outline, manual, and any additional materials that would be helpful in evaluating the course. SECTION III SPECIFIC COURSE INFORMATION REQUIREMENTS FOR EACH COURSE TYPE (Please refer to attached course outlines. These lists are not exclusive.) On a separate piece of paper: a. give a brief description of how the course covers each of the subjects listed in the Course Outline. b. identify the areas in your attached agenda/course outline that correspond to each subject; and c. identify the approximate time spent on each of the subjects. SECTION IV BACKGROUND 1. Have you ever been convicted of, or plead guilty or nolo contendere to violations of the law, including traffic violations resulting in suspension or revocation of a driver's license and DUI DUI offenses? Yes No If Yes, please list and include the specific code section(s) violated. Please see Sections G.1. and G.2 of the Guidelines. 2. Have you ever 1) had a disciplinary action related to a profession, including mediation (for example, a professional license suspended or revoked); 2) had any professional privileges curtailed; and/or 3) relinquished a professional privilege or license while under investigation? Yes No If Yes, describe on the lines provided below. 3. If you answered "Yes" to question #1 or #2 above, please describe the impact, if any, this could have on your ability to provide mediation training. FORM ADR-2000 July 2011 3 American LegalNet, Inc. www.FormsWorkFlow.com SECTION V CERTIFICATION I understand that information regarding this course may be provided to individuals seeking training by the Office of the Executive Secretary. I hereby certify that the information provided in this application is true to the best of my knowledge. I understand that all information herein is subject to verification and that the training may be observed at any time by a representative of the Office of the Executive Secretary as a part of the certification process. I hereby certify that I have read the Standards of Ethics and Professional Responsibility for Certified Mediators adopted by the Judicial Council of Virginia effective July 1, 2011, and that the course described herein will provide training in accordance with these Standards. Signature of Person Responsible for Providing Training Date A $25.00 check or money order must accompany this application. Please make check payable to the Treasurer of Virginia. Do not send cash. Please forward this application and check to: Dispute Resolution Services Office of the Executive Secretary 100 N. Ninth Street, Third Floor Richmond, VA 23219 If you have any questions or comments, please contact Dispute Resolution Services, 804-786-6455. Supreme Court of Virginia FORM ADR-2000 July 2011 4 American LegalNet, Inc. www.FormsWorkFlow.com