Application for Basic & Family Mediation Training

Individuals interested in receiving 40-Hour Basic Mediation Training or 30-Hour Family Mediation must submit a training application and training fee. Since seating is limited, we strongly encourage training applications and fees be submitted on the same day. Payments for classes in 2019 will be accepted beginning Jan. 1st.

The preferred method of payment is by credit or debit card. Please call (817) 877 – 4554 during regular business hours (8:00 AM – 5:00 PM Monday through Friday) to pay by credit or debit card. Payments in the form of a money order, personal check, or cashier’s check should be made payable to DRS North Texas and mailed to: P. O. Box 172661, Arlington, Texas 76003.

TRAINING APPLICATION

Personal Information

Name:

Preferred Name:

Mailing Address:

Street

City/State

Zip Code

Birth Date: (Format: MM-DD-YYYY. Ex: 01-25-1985)

Email:

Primary Phone:

How were you referred to DRS North Texas Inc.?

Employment

Are you employed?

If "Yes," where?

Profession/Title:

Years of Experience:

Please check all applicable work experience:
ADRArmed ForcesAttorneyBusiness/FinanceClergyConstructionEducation (K-12)Education (University)HRITLaw EnforcementMarketing/PRMedicalParalegalReal EstateSocial WorkOther

Armed Forces, if selected please specify:

If other, please specify:

Have you ever been convicted of a crime, other than minor traffic violations?

if "Yes," please explain:

Do you have a medical condition, take any medications, or have a disability, which we should know about for your safety or comfort?

if "Yes," please explain:

Do you speak a foreign language?

if "Yes," what language?

Can you write in the foreign language?

Can you interpret in the foreign language?

Education

High School:

Name of Institution:

Graduated?

Year:

College/University

Name of Institution:

Graduated?

Degree:

Year:

College/University

Name of Institution:

Graduated?

Degree:

Year:

Voc/Bus

Name of Institution:

Graduated?

Degree:

Year:

References:

Please list two persons, not related to you, and you have known at least one year.

Reference 1

Name:

Phone:

Email:

Relationship:

Reference 2

Name:

Phone:

Email:

Relationship:

Mediation Experience

Have you served as a mediator before?

If “Yes,” where did you receive Basic Mediation Training?

How many cases have you mediated?

What types of cases?

Are you interested in volunteering as a mediator for DRS North Texas Inc.?

Note: Mediations are scheduled for half a day Mon. - Fri. at 9:00 AM, 9:30 AM, 1:00 PM, and 1:30 PM.

Why do you want to become a volunteer mediator?

In case of an emergency, please provide a contact person:

Name:

Phone:

Relationship:

Please read the following sign and date.

I affirm that all information given is true to the best of my knowledge.

I understand Dispute Resolution Services of North Texas (DRS NORTH TEXAS INC.) teaches mediation to prepare individuals to volunteer as mediators at DRS NORTH TEXAS INC.

I understand that:

a) my service as a DRS NORTH TEXAS INC. volunteer mediator is a privilege; and
b) knowingly submitting false information; and/or failing to abide by DRS NORTH TEXAS INC. established standards of performance and/or behavior may result in dismissal from the Volunteer Mediator Program at the sole discretion of DRS NORTH TEXAS INC.

I agree to abide by all obligations and rules relevant to service as a volunteer mediator of DRS NORTH TEXAS, INC.

I grant permission to DRS NORTH TEXAS INC.:

a) to post photos, video, or other items of my participation in training on their social media accounts, websites, and printed marketing materials, hereinafter referred to as "Materials";
b) I release the agency, the agency's representatives, employees, managers, officers, and directors, from all claims and demands arising out of or in connection with any use of said "Materials"; and
c) I acknowledge and agree that no sums whatsoever will be due to me as a result of the use of the "Materials" or any rights therein.

Printed Named:

Date:

Training Fees

40-Hour Basic Mediation Training
Regular Price $550
Early Registration $499

30-Hour Family Mediation Training
Regular Price $325
Bundled with Basic $299

A training fee is required to finalize registration for Basic or Family Mediation Training. Fees can be submitted by credit card, money order, personal check, or cashier's check.

To pay by credit or debit card, please call (817) 877 - 4554 during regular business hours Monday through Friday 8:00 AM - 5:00 PM. Money orders, personal checks, and cashier's checks should be made payable to DRS North Texas and mailed to: 4304 Airport Freeway, Suite, 100, Fort Worth, Texas, 76117.

Are you registering for the 40-Hour Basic Mediation Course? Year:

Are you registering for the 30-Hour Family Mediation Course? Year:

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