A mediator is encouraged to join with other mediators and members of related professions to promote mutual professional
development. Pursuant to criteria in Rules of 
, a mediator should obtain at least four (4) hours of continuing education every
two (2) years. For additional information, please refer to www.kycourts.net.
Name: _____________________________________________________________
Today’s Date: _____________________________ Email Address: _____________________________
Address: ___________________________________________________________
Please return this form to:
Administrative Oce of the Courts
Mediation Oce
1001 Vandalay Drive
Frankfort, KY 40601
Email: mediation@kycourts.net
Rev. 11-18
Page 1 of 1
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
*Indicate if the hours you are claiming were obtained from: (1) attending, lecturing, or teaching at a live lecture or seminar
on a topic related to the practice of mediation; (2) listening or viewing audio, or web based presentations on a topic related
to mediation; (3) co-mediating or supervising trainees as part of the trainees mentorship requirements; (4) participating as
a trainer or coach in general or family mediation trainings;(5) authoring or editing written materials submitted for publication
that have signicant intellectual or practical content directly related to the practice of mediation; (6) other resources (please
specify below).
For Oce Use Only
App Rec’d ______ / ______ /______
App Approved ______ / ______ / ______
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