OFFICE OF JUDICIAL ADMINISTRATION
DIRECTOR OF DISPUTE RESOLUTION
301 SW 10
TH
AVE
TOPEKA, KS 66612
ADR@KSCOURTS.ORG
Dispute Resolution Provider Renewal Instructions
1. This form should be submitted for consideration of annual renewal of Dispute Resolution
Provider in the following categories
Mediation
o Core
o Domestic
o Parent Adolescent
o Civil
o Juvenile
o Mentor
Domestic Conciliator
Parenting Coordinator
Case Management
2. A renewal application will need to be completed and submitted each new calendar year to
remain active.
3. A new application is required when requesting approval in any of the above categories even
if you are approved in another category. You may submit a new application with your
renewal to be processed at the same time and only pay one application fee.
4. The fee is waived if the applicant is providing services as a court employee or is a volunteer
for an approved program.
5. Renewals must be submitted via mail to the address below unless you qualify for a fee
waiver, in that event you may email the application to the email address below.
6. The renewal application and fee must be postmarked by January 30. Renewal applications
postmarked after January 30
th
will be $75 (a $25 reinstatement fee in addition to the $50
renewal fee).
Required Attachments:
Copies of all CDRE hours or training certificates (if not already submitted);
o Timed agenda for unapproved hours;
$50.00 Application fee (an additional $25 reinstatement fee if renewal is
submitted after January 30
th
); and
If requesting waiver of any required qualification, a letter must be included with
your renewal application along with any supporting documentation, experience,
or training requested for substitution.
INCOMPLETE RENEWALS WILL BE RETURNED WITHOUT REVIEW
OFFICE OF JUDICIAL ADMINISTRATION
DIRECTOR OF DISPUTE RESOLUTION
301 SW 10
TH
AVE
TOPEKA, KS 66612
ADR@KSCOURTS.ORG
Approved
Denied
Fee
Date of Decision
Enclosed Waived
Core Civil Domestic
Parent
Adolescent
Juvenile
Dependency
Mentor
Parenting
Coordinator
Case
Management
Dispute Resolution Provider Renewal
Individual Information
Name:
DPR#: Current CDRE Hours:
Address:
City, State, Zip:
Phone: Fax#:
Email:
Renewal Information
Categories in which you are requesting renewal:
Mediation Domestic Conciliator
Core Parenting Coordinator
Civil Case Management
Parent/Adolescent
Juvenile Dependency
Domestic
Mentor Mediation
If you are mentor mediator, which types of mediation do you mentor?
Core
Civil
Parent/Adolescent
Juvenile Dependency
Domestic
If you are not previously approved in any of the above listed processes, please apply for
initial approval as required by Supreme Court Rule 911.
Office Use Only
Office Use Only
OFFICE OF JUDICIAL ADMINISTRATION
DIRECTOR OF DISPUTE RESOLUTION
301 SW 10
TH
AVE
TOPEKA, KS 66612
ADR@KSCOURTS.ORG
Are you requesting a waiver in any category? Yes No
If yes, include a letter along with any supporting documentation, experience, or training
requested for substitution.
Do you conduct dispute resolutions as a court employee? Yes No
Are you a court services officer? Yes No
Do you conduct dispute resolution as a non-court Yes No
State of Kansas employee?
Are you a licensed attorney? Yes No
Would you like your contact information published on
www.kscourts.org for referral purposes? Yes No
What districts are you willing to mediate in?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
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30
31
Additional areas of expertise, if any, to add:
Dispute Resolution Provider Annual Statistical Information
Number of Mediations: Count each case just once (example 5 Community).
Domestic (Custody/Parenting Plan) Civil Rights Family
Domestic (Full Case) Agricultural Employment
Domestic (Property) Special Education Malpractice
Parent/Adolescent Environmental Small Claims
Limited Actions Consumer Community
Victim/Offender Workers Comp Probate
Personal Injury Public Policy Church
Juvenile Dependency
Other:
OFFICE OF JUDICIAL ADMINISTRATION
DIRECTOR OF DISPUTE RESOLUTION
301 SW 10
TH
AVE
TOPEKA, KS 66612
ADR@KSCOURTS.ORG
Number of Other Forms: including domestic conciliator, parent coordinator, case mangement,
arbitrations, settlement conferences, neutral evaluations, etc. Count each case just once.
Domestic (Custody/Parenting Plan) Civil Rights Family
Domestic (Full Case) Agricultural Employment
Domestic (Property) Special Education Malpractice
Parent/Adolescent Environmental Small Claims
Limited Actions Consumer Community
Victim/Offender Workers Comp Probate
Personal Injury Public Policy Church
Juvenile Dependency
Other:
If no services were provided during the prior year, please indicate here: _________
Optional Information
What language(s), other than English, can you use in Dispute Resolutions?
Estimated average number of hours per case:
This includes preparation, paperwork, and actual work with parties
Average fee per hour:
Comments and Suggestions:
Have major changes occurred this year in how dispute resolution is conducted or are there any
dispute resolution programs/services which have begun in the past year in your judicial district?
OFFICE OF JUDICIAL ADMINISTRATION
DIRECTOR OF DISPUTE RESOLUTION
301 SW 10
TH
AVE
TOPEKA, KS 66612
ADR@KSCOURTS.ORG
D. Verification:
I declare, under penalty of perjury, that all information I have supplied in applying for program approval is truthful
and accurate. I agree, individually and on behalf of the program named in this application, (1) to uphold the
Kansas Supreme Court Rules Relating to Dispute Resolution; (2) to assure that my or the program’s approved
training courses or approved CDRE presentations will meet the requirements of SC Rule 914 or SC Rule 916,
respectively; (3) to submit myself or the program I represent to periodic supervision and evaluation, and release
any information concerning such supervision or evaulation to the Director of Dispute Resolution while I am serving
as an approved program or representing an approved program. In addition, I understand that to gain and maintain
approval, I shall provide a program annual report to the Director of Dispute Resolution each calendar year.
Signature
Date
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