TRAINING APPLICATION
Personal Information
Employment
Please check all applicable work experience:
ADR Armed Forces Attorney Business/Finance Clergy Construction Education (K-12) Education (University) HR IT Law Enforcement Marketing/PR Medical Paralegal Real Estate Social Work Other
Armed Forces, if selected please specify:
If other, please specify:
Have you ever been convicted of a crime, other than minor traffic violations? --- Yes No
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? --- Yes No
if "Yes," please explain:
Education
High School:
College/University
College/University
Voc/Bus
References:
Please list two persons, not related to you, and you have known at least one year.
Reference 1
Reference 2
Mediation Experience
Are you interested in volunteering as a mediator for DRS North Texas Inc.? --- Yes No
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:
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.
Training Fees
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? --- Yes No Year:
Are you registering for the 30-Hour Family Mediation Course? --- Yes No Year:
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