NCRC Mediator Credential Application

(619) 238-2400

Mediation

Divorce & Family Services

Org. Development

Thank you for your interest in our Credentialing Program. Once this form is submitted you will be contacted to discuss your application. Please be sure to attach a resume with this application. You will have the opportunity to do so at the bottom of this form. Please note that the application is not complete until the non-refundable $50.00 application fee is received. The application fee can be paid while submitting this form or you can mail payment directly to NCRC upon completion of this form.

Name:

Address:

City:

State:

Zip:

If this is a work address, please provide company name and your title

Cell Phone:

Work Phone:

Ext:

Email:

Applying For:

Option A - Standard Track ($3,500) Tuition

2 Observations.
6 Mediations: 4 co-mediations of actual cases, 2 solo mediations of simulated cases
Mid-term coaching
Final Performance Evaluation

Option B - Court Track ($3,500) Tuition

2 Observations
6 Mediations: 6 co-mediations of actual cases
Mid-term coaching
Final Performance Evaluation

Option C - Court Track + Two ($3,900) Tuition

2 Observations
8 Mediations: 6 co-mediations of actual cases, 2 solo mediations of simulated cases
Mid-term coaching
Final Performance Evaluation

Option D - Customized Credentialing Program (Cost negotiated individually)

An individualized credentialing program will be designed for candidates who have received training elsewhere (not through the NCRC Training Institute) and/or who have prior actual mediation experience. Curriculum is customized to ensure that candidates are prepared with sufficient training experience, and coaching for the Final Performance Evaluation.

Your Previous Dispute Resolution Training

Have you completed NCRC's 32-hour introductory Mediation Skills Training?:

Yes

Date of Training:

Please Describe any other mediation training you have received. Include: name of provider, course name, dates, number of hours devoted to lecture/discussion, number of hours devoted to practical skills (role plays, observations, etc.)

Describe other related training: arbitration, facilitation, negotiation, etc.

This Section is Only For Applicants to the Customized Credential Program

Please complete this section if you wish to use previous mediation training from a provider other than NCRC to meet credentialing training requirements

Has your previous training addressed these issues? (Check if "yes") :

Dispute Resolution Context:
Dispute resolution theory	ADR history
Mediation models	Mediation process design
Role of attorney's in mediation	Relationship to traditional legal services in the court
Communication Skills:
Opening statements	Fact gathering, clarifications
Reframing	Effective listening
Process Management Techniques:
Agenda setting	Brainstorming, generating settlement options
Handling impasse	Use of evidence and witnesses

Please describe your previous mediation experience if you wish to apply that experience toward the mediator credentialing requirement of six mediations (approximately twenty hours of mediating) within the past five years. Include the following information about cases in which you were the mediator. Use an additional sheet if more space is needed.

Previous Mediation Experience #1

Date:

Location:

Duration:

Type of Case:

Supervising Agency:

Solo or Co-Mediation:

Solo

Co-Mediation

Previous Mediation Experience #2

Date:

Location:

Duration:

Type of Case:

Supervising Agency:

Solo or Co-Mediation:

Solo

Co-Mediation

Previous Mediation Experience #3

Date:

Location:

Duration:

Type of Case:

Supervising Agency:

Solo or Co-Mediation:

Solo

Co-Mediation

Previous Mediation Experience #4

Date:

Location:

Duration:

Type of Case:

Supervising Agency:

Solo or Co-Mediation:

Solo

Co-Mediation

Other related experience: arbitration, facilitation, negotiation, etc.

Arbitration:

Facilitation:

Negotiation:

Other:

Biographical Information (All Applicants)

Please provide a brief "letter of interest" about why you wish to become a credentialed mediator.

Please attach a resume with employment history, education, and any other information that would be helpful in assessing this application

File:

Or Paste:

Personal Reference

Name:

Address:

Phone:

Email:

Relationship to Applicant:

Payment

I will pay the non-refundable $50 application fee right now online via credit card (fee will be credited toward tuition if application accepted)

I will mail a check to the National Conflict Resolution Center, Attn: Credentialing Dept.,
625 Broadway, Suite 1221, San Diego, CA 92101
(fee will be credited toward tuition if application accepted)

I certify that the above information is complete and correct. I give the National Conflict Resolution Center permission to verify any information provided on this application.

I agree