Fillable Approval of Individual Dispute Resolution Providers Instructions (Kansas Judicial Branch)

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Approval of Individual Dispute Resolution Providers Instructions (Kansas Judicial Branch)

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Approval of Individual Dispute Resolution Providers – Instructions
1. This form should be submitted for consideration of approval to become a dispute
resolution provider pursuant to Supreme Court Rule 911.
2. Approval is granted on an annual basis. An application for renewal, with continuing
dispute resolution education credits, must be completed each calendar year to remain
active.
3. A new application is required when requesting approval in any dispute resolution
category other than the one for which the applicant is already approved. If applications
are submitted separately, an application fee will need to be submitted with each.
However, if the applications are submitted at the same time, only one application and
application fee is required.
4. The application fee is waived if the applicant provides services as a court employee or
receives no compensation for providing the dispute resolution services for which
approval is sought.
5. Notice of approval will be emailed to the individual.
7. Completed applications (and any attachments) should be submitted to the Director of
Dispute Resolution via mail (or email only if applicant qualifies for a fee waiver) to:
Office of Judicial Administration
301 SW 10
th
Avenue
Topeka, KS 66612-1507
adr@kscourts.org
Required Attachments:
Copies of all verifying licenses, certificates, or training affidavits.
A non-refundable $50.00 application fee.
Descriptions or syllabi of relevant training attended if not state-approved.
Writing sample related to the category of approval being applied for (do not include the
names of the participants).
Personal statement of the applicant's motive for seeking approval.
2
Approval of Individual Dispute Resolution Providers –
Instructions
Required Attachments (continued)
Two letters of recommendation attesting to the applicant's character, temperament,
experience, and requisite mental and emotional fitness to engage in the active and
continuous practices of dispute resolution.
Documentation that the applicant has satisfied the applicable requirements under
Supreme Court Rule 911(c).
Sliding scale system for assessing fees (if applicable).
Any other documentation required pursuant to Supreme Court Rule 911.
If requesting mentor mediation approval, two letters of recommendation from people
who will attest to the applicant's character and capacity to serve as a mentor mediator.
If requesting waiver of any required qualification, a letter including documentation of
relevant experience, training, or other information supporting the requested waiver.
INCOMPLETE APPLICATIONS WILL BE RETURNED WITHOUT REVIEW
1
Office Use Only
Approved Denied Fee Date of Decision
Enclosed
Waived
Mediators Other Dispute Resolution
Core Parent Adolescent Domestic Conciliator
Civil Juvenile Dependency Parenting Coordinator
Domestic Mentor Case Manager
Approval of Individual Dispute Resolution Providers – Application
Part A: Individual Information (Required on all applications)
Name: DRP#:
Address:
City, State, Zip:
Phone:
Email (Required):
Part B: Application Information (Required on all applications)
Categories in which you are requesting approval:
Mediator: Core Other Dispute Resolution: Domestic Conciliator
Civil Parenting Coordinator
Parent/Adolescent Case Manager
Juvenile Dependency
Domestic
Mentor Mediator
Are you requesting a waiver of the requirements for approval in a category? Yes No
(If yes, written documentation must be provided explaining the reason for the request.)
Are you requesting a fee waiver? Yes No
If yes, for what reason?
Do you conduct dispute resolution as a court employee? Yes No
Are you a court services officer? Yes No
Do you conduct dispute resolution as a non-court State of Kansas employee? Yes No
Are you a licensed attorney? Yes No
Would you like your contact information published on the Judicial Branch internet Yes No
site for referral purposes?
2
Which judicial districts are you willing to provide dispute resolution services?
What language(s), other than English, can you provide dispute resolution services?
Areas of Expertise
Probate Limited Actions Small Claims
Malpractice Employment/Workplace Consumer
Personal Injury Domestic/Custody Civil Rights
Public Policy Agricultural Environmental
Special Education Victim/Offender Church
Other
History
Have you been convicted of a felony or misdemeanor? Yes No
If yes, provide dates of conviction, charges convicted of, and courts where convicted.
Has a formal complaint concerning dispute resolution ever been filed against you? Yes No
If so, explain.
Have you ever had a professional license suspended/terminated? Yes No
If yes, provide dates of suspension or termination, by whom, for what period, and reason for suspension
or termination.
Post-Secondary Education
School Name:
Address:
Attended: to Credit Hours:
Major: Degree:
Minor or Certificate:
3
School Name:
Address:
Attended: to Credit Hours:
Major: Degree:
Minor or Certificate:
Professional Licenses or Registrations
Type:
Conferring Entity: Location:
Date Issued/Renewed: Expiration:
Type:
Conferring Entity: Location:
Date Issued/Renewed: Expiration:
Part C: Verification
I, , certify that all information I have supplied in applying for dispute
resolution provider approval is true and complete. I agree to uphold the Kansas Supreme Court Rules Relating
to Dispute Resolution. I also agree to submit to periodic supervision and evaluation, and release of any
information concerning my supervision or evaluation to the Director of Dispute Resolution while I am serving
as an approved dispute resolution provider. In addition, I understand that to gain and maintain approval, I
must provide statistical information to the Director of Dispute Resolution on an annual basis.
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Approval of Individual Dispute Resolution Providers Instructions (Kansas Judicial Branch)

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Completed 20 March 2021

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