2017 - Accredited Mediators

Mediator Registration Form

2017 - Accredited Mediators

To register with the FMC for 2017 as an accredited mediator, please complete this form and pay your registration fee for the period 1 January to 31 December 2017.

Before doing so, please read the accompanying information sheet about accredited mediators registering with the FMC in 2017.

Once you have completed this form and saved it please return it with scanned copies of relevant certificates to , and pay the £100 fee.

Please pay online using the following details, recording your name in the reference box.

Account name: Family Mediation Council

Account number: 21649388Sort Code: 40-24-13

If you do not put record your name in the reference box your registration may be delayed.

Alternatively you may pay by cheque payable to Family Mediation Council, with your name recorded on the back. Please send your cheque, accompanied by a covering note, to: Family Mediation Council, 2 Old College Court, 29 Priory Street, Ware, Hertfordshire, SG12 ODE.

Section 1 – Name and Professional Information

This information will be made available to the public.

Title / Miss / Mr / Mrs / Ms / Dr / Prof
(Please delete as appropriate)
Last Name
First Name
Membership organisation / ADRg
College of Mediators
FMA
The Law Society
NFM
Resolution
(Please delete as appropriate)
The datethat FMCA status or the qualification which led to this was achieved. / Date (dd/mm/yy):
The basis on which you qualify for FMCA status (e.g. APC, UK College of Mediators, Law Society Accreditation, FMA Senior Mediator Status, Resolution Accreditation).
Are you accredited for All Issues or Child Only mediation? / All Issues / Child Only
(Please delete as appropriate)
Are you qualified to carry out publicly funded work (legal aid)? / Yes / No
(Please delete as appropriate)
Do you have, or work for a service which has, a Legal Aid franchise? / Yes / No
(Please delete as appropriate)
If you qualified to carry out direct consultation with children, the date of training for this* / Date (dd/mm/yy):
If you are qualified to carry out direct consultation with children, the date and type of your most recent DBS check. / Date (dd/mm/yy):
Basic DBS Check / Enhanced DBS Check / Enhanced DBS Check with Barred Lists Check
(Please delete as appropriate)
Are you a PPC? / Yes / No
(Please delete as appropriate)
If you are a PPC, the date of your training*. / Date (dd/mm/yy):
You own PPC’s Name.
Your PPC’s Unique Registration Number (URN).
The names of any other PPCs you have had in the previous 12 months.

* Please send scanned copies of relevant certificates along with your completed registration form.

Section 2- Practice Information

This information will be made available to the public. Please provide details of all those practices you actuallypractise from.This is to ensure that the public can find all the mediators working within a 15 mile radius of their home address, and to help people who need to use a family mediation service to contact you.

Name of practice
Address / Address Line 1:
Address Line 2:
Town:
Postcode:
Telephone number
E-mail address
Website

If you need to list more than one practice, please use the Supplementary Practice Form and return this along with the completed registration form.

Section 3- Contact Details

You must supply us with one contact address, phone number and e-mail for the purposes of verification and to allow us to communicate with you. However, unless you choose to use your practice information (and therefore repeat here thatwhich is listed above) for this, it will not be made public.

Email address
Telephone number
Address / Address Line 1:
Address Line 2:
Town:
Postcode:

The FMC (including FMSB) will use these details to send you information about registration, accreditation and standards. If you would alsolike to receive newsletters and other updates about the FMC and FMSB’s work, please select this box:

Section 4- Declaration

1. I certify thatI am entitled to claim FMCA status and that throughout 2015 and 2016 orsince becoming accredited (if later) I have:

1. Been a member of an FMC membership organisation; and
2. Carried out the required level of continuing development, received the required support from a Professional Practice Consultant, and met the minimum expected level of practice in accordance with the FMC Manual of Professional Standards and Self-Regulatory Framework.

1. I certify that the information I have provided on this form is correct.

1. I consent to this data being captured and stored electronically or otherwise by and on behalf of The Family Mediation Council in accordance with the provisions of the Data Protection Act 1998.

1. I confirm that payment of £100 by BACS on from an account in the name of .

OR

I confirm that a cheque for £100 has been sent via post on

from an account in the name of .

Name:

Date:

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