Application for Community Mediation Training

I. Contact Information

Name: ______Date: ______

Address: ______Eve Phone: ______

City: ______Zip: ______Cell Phone: ______

E-Mail:______Day Phone: ______

How did you hear about NCRC? ______

______

II. Background

Gender: c Female c Male Age: ______

Religion (if applicable): ______Race/ethnicity: ______Country of birth: ______

Languages spoken, other than English: ______

Languages written, other than English: ______

Current Employment: ______Salary: ______

Former Employment: ______

Highest level of education completed (check one): c High School c College c Graduate School

Dates of study: ______Name of School: ______

Subject studied / Degree earned: ______

______

5-10 words that describe yourself: ______

______

III. Questions:

1. What interests you about conflict resolution & why do you want to take this mediation training?

2. What experience and/or skills do you have which you think would make you a good mediator?

3. What experience do you have volunteering in the community? How much time did you commit to that work and during what period of time?

4. What days and times during the week are you available to mediate? (NCRC mediation sessions range from 1-5 hours in length, and are regularly scheduled during business hours.)

IV. Application Deadlines:

August 16 Application Due – pgs 1-3

Submit by Fax (615-296-4336), Email () or regular post: NCRC, 4732 W. Longdale Drive, Nashville, TN 37211

August 28-30 Interviews

Sept 3 Notification of Acceptance

Sept 9 Deposit due (50% of training fee)

Sept 15 Balance due (Remaining 50%) - Check, cash or money order

V. Interviews:

VI. Registration: Select one training track

1 / Community Mediation Training (40 hrs)
-Including-
Apprenticeship & Volunteer Requirement / $475
2 / Community Mediation Training (40 hrs)
-Including-
Apprenticeship & Volunteer Requirement, and Rule 31 Civil Listing option* / $575
3 / Community Mediation Training (40 hrs)
NO APPRENTICESHIP & VOLUNTEER REQUIREMENT
Rule 31 Civil Listing option* / $1,150

Training includes snacks and materials

Sample topics covered:

Apprenticeship & Volunteer Requirement: NCRC requires all trained volunteers to complete an Apprenticeship comprised of two (2) observations and three (3) co-mediation sessions. After the Apprenticeship, volunteers must co-mediate a minimum of twelve (12) civil, victim offender and/or community cases within one year. NCRC reserves the right to bill trainees for the remaining balance of training if these requirements are not met.

*Rule 31 Civil Listing option: To become listed as a Rule 31 (i.e. state-certified) Civil Mediator, one must have a graduate degree plus four years of practical work experience, or a baccalaureate degree plus six years of practical work experience. See http://tncourts.gov/rules/supreme-court/31

Per Rule 31 Section 17, a Rule 31 applicant has up to 15 years after completing training to meet the Rule 31 requirements.

NCRC does not require its volunteer mediators to meet the Rule 31 formal education & work experience standards outlined above.

The registration fee for applicants seeking Rule 31 Civil Listing (track #2) includes an additional $100 that NCRC pays directly to the ADR Commission of the TN Supreme Court per its guidelines. Applicants must note that they will also pay a Rule 31 application fee of $100 to the ADR Commission after completing the training (and Apprenticeship).

A limited number of scholarships are available if your annual income is $35K or less. / Request a Scholarship
______

I agree to attend all training sessions, if selected to participate in the NCRC Community training.

Signature: Date:

______