Mediator Re-registration Form

2017

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

Completing this form

This form is divided in to five sections.

·  Section 1 asks you to confirm or correct information currently held, apart from contact and practice information.

·  Section 2 asks you complete new fields, if relevant to you.

·  Section 3 relates to practice information. This information will replace the practice information currently available through the FMC’s Find A Mediator Search.

·  Section 4 relates to contact information and your communication preferences.

·  Section 5 asks you to confirm that your professional development is up to date, that all the information you have provided is accurate, and that you give the necessary consent for the FMC to store the information provided.

2017 Fees

If you hold FMCA, the fee for 2017 is £100.

If you are a family mediator working towards FMCA status, the fee for 2017 is £50.

Returning this form and paying the fee

Please complete this form electronically. Please note that incomplete forms will be returned to be fully completed.

Once you have completed and saved it, please return it with scanned copies of relevant certificates to by 5th February 2017.

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

Account name: Family Mediation Council

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

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

Alternatively you may pay by cheque payable to Family Mediation Council, with your name and URN 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 – Confirmation of Existing Details

1.  My URN is

2.  I have read the information you currently hold about me in the FMC Register and confirm it is correct.

OR

I have read the information you currently hold about me in the FMC Register and confirm it is correct, save for the information below.

NB Please only complete the boxes for information that has changed or needs correcting.

Title / Select
Last Name
First Name
Membership organisation / ADRg
College of Mediators
FMA
The Law Society
NFM
Resolution
If you hold FMCA, the date this (or qualification which led to this) was achieved. / dd/mm/yy
If you are working towards FMCA, the date you successfully passed your training course. / dd/mm/yy
If you are working towards FMCA, who you carried out your training with.
Are you qualified to carry out publicly funded work (legal aid)? / Select
Do you have, or work for a service which has, a Legal Aid franchise? / Select
Are you qualified to carry out direct consultation with children? / Select
Are you a PPC? / Select
You own PPC’s Name.
Your PPC’s URN.
The names of any other PPCs in the previous 12 months.

Section 2 – New Information

If you transferred in to FMCA on 1.1.15, the basis on which you did so (e.g. APC, UK College of Mediators, Law Society Accreditation, FMA Senior Mediator Status, Resolution Accreditation).
If you hold FMCA, are you accredited for All Issues or Child Only mediation? / Select
If you are qualified to carry out direct consultation with children, the date of training for this. / dd/mm/yy
If you are qualified to carry out direct consultation with children, the date and type of your most recent DBS check. / dd/mm/yy
Select
If you are a PPC, the date of your training. / dd/mm/yy

Section 3 - Practice Information

This information will be made available to the public. Please provide details of all those practices you actually practise 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 Re-registration form.

Section 4 - 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 that which 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 also like to receive newsletters and other updates about the FMC and FMSB’s work, please select this box:

Section 5 - Declaration

1.  I certify that in 2016, I 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.

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

3.  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.

4.  I confirm that payment of [select fee] by BACS on dd/mm/yy from an account in the name of .

OR

I confirm that a cheque for of [select fee] has been sent via post on dd/mm/yy from an account in the name of .

Name:

Date: dd/mm/yy

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