Fillable Application To Be Placed On The Mediation Roster (Administrative Office of the Courts)

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Application To Be Placed On The Mediation Roster (Administrative Office of the Courts)

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This application will be considered pursuant to criteria ordered as Rules of Administrative Procedure AP Part XII, Mediation
Guidelines for Court of Justice Mediators. Please read all instructions carefully.
APPLICATION TO BE PLACED ON THE
MEDIATOR ROSTER
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Training and Experience
A mediator who oers to provide general mediation services should have the following minimum training and experience:
(a) Forty hours of training with an approved mediation training program covering communication skills; conict resolution theory and
practice; mediation theory, practice, and techniques; the court process; and,
(b) Fifteen hours of participation in actual dispute mediation, in at least three cases, under the guidance of a mediator qualied under
these Guidelines or a mediation training center.
AOC- MED-ADR-7
Rev. 11-18
Page 1 of 3
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
AP Part XII
Section II. General Mediation: (Complete this section if you would like to be placed on the roster as a General Mediator.)
Training Provider Location Training Dates Number of Hours
I have completed a general mediation training and mediation experience as required in Section II (a) and (b).
q YES q NO
What organization provided your training and when? (See below.)
List areas of experience
(ex: contracts)
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Section I. General Information:
Name (Last, First, Middle): ___________________________________________________________
Mailing Address: ___________________________________________________________________
___________________________________________________________________
Phone: _____________________ E-mail: _____________________ County: _____________________
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
For Oce Use Only
App Rec’d ______ / ______ /______
Reviewed ______ / ______ / ______
Application Approved q YES q NO
Action Taken: ___________________
AOC-MED-ADR-7
Rev. 11-18
Page 2 of 3
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Pursuant to Section 2(3) of the Guidelines, any mediator who has not completed general mediation training and/or the
mediation experience as noted in Section II (a) and (b) above, and has engaged in a mediation practice prior to April 15,
2005, when these Guidelines were adopted, may be qualied by equivalent training and experience. Please describe below
what you believe is equivalent to the training and experience suggested by these Guidelines. (Use extra sheet if necessary.)
Section III. Family Mediation: (Complete this section if you would like to be placed on the roster as a Family Mediator.)
Training and Experience
A mediator who oers to provide family mediation services should have the following minimum training and experience:
(a) Forty hours of training with an approved mediation training program covering conict resolution, the mediation process, communication
skills, the psychological aspects of divorce on families, domestic violence, substance abuse, nancial and property issues, paternity,
family law, and family or circuit court procedures. Family mediators are strongly encouraged to take general mediation training prior
to this training; and,
(b) Fifteen hours of participation in actual dispute mediation, in at least three cases, under the guidance of a family mediator qualied
under these Guidelines or a mediation training center.
Training Provider Location Training Dates Number of Hours
I have completed a family mediation training and mediation experience as required in Section II (a) and (b).
q YES q NO
What organization provided your training and when? (See below.)
List areas of experience (ex: contracts)
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
AOC-MED-ADR-7
Rev. 11-18
Page 3 of 3
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Case Name: Court: Date: Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Pursuant to Section 2(3) of the Guidelines, any mediator who has not completed family mediation training and/or the mediation experience
as noted in Section III (a) and (b) above, and has engaged in a mediation practice prior to April 15, 2005, when these Guidelines were
adopted, may be qualied by equivalent training and experience. Please describe below what you believe is equivalent to the training
and experience suggested by these Guidelines. (Use extra sheet if necessary.)
I, _____________________________________________, swear/arm that the information supplied on this application is
correct. I understand that falsications, misstatements or misrepresentations above may disqualify me from being placed
on the mediators’ roster. I further certify that I have read and understand the Mediation Guidelines for the Court of Justice
Mediators, agree to adhere to the ethical guidelines as stated in Section 3, and agree to my name and contact information
being placed on the Mediators Roster with the Mediation Division of the Administrative Oce of the Courts.
_______________________________________________ _______________________________
Signature of Applicant Date
Please return this form to:
Administrative Oce of the Courts
Mediation Oce
1001 Vandalay Drive
Frankfort, KY 40601
Email: mediation@kycourts.net
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Application To Be Placed On The Mediation Roster (Administrative Office of the Courts)

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Completed 27 January 2021

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