MMS Program of Supervised/Mentored Mediator Placement

* Required information

WHAT WOULD YOU LIKE TO DO TODAY?

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(please choose one)
- Apply for Supervised/Mentored Mediation Placement (requires weekly commitment for 6 months)
- Make a payment on a previously-submitted Supervised/Mentored Mediation application
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If you have already completed this application and are ONLY here to make a payment, please complete the next four fields (name and email) then SKIP TO the fee-related sections.

Type	Fee
Supervised Mediation Tuition, including $100 deposit (THANKS FOR PAYING IN FULL)	$750.00
Tuition Deposit ONLY (PAY BALANCE LATER)	$100.00
Tuition Balance (IF YOU PAID THE DEPOSIT PREVIOUSLY)	$650.00
Other Amount (FILL IN $ IN THE "OTHER AMOUNTS" SECTION BELOW)	No Charge

Where did you receive your prior course of mediation training?
- From Metropolitan Mediation Services
- Outside of MetroMediation (Please submit completed training & mentoring certification forms.)
Approximate END date of your prior mediation training?
If you received your prior course of mediation training outside of MetroMediation, please indicate: NAME of program/organization conducting the training, NAME of lead trainer(s), PHONE & EMAIL CONTACT INFO for lead trainer who can provide a reference, if available.
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Total number of training hours in your prior course:
- Less than 25
- 25-29
- 30-40 (the MetroMediation course is 36 hours)
- More than 40
If you received your prior mediator training from MMS, we will contact applicants if we need further information.
If you received your prior mediator training from a source other than MMS, you must also submit the following 4 items before your application will be considered:
1) A completed certification of training form linked here https://www.dropbox.com/s/52djmsa4u7zaave/TrainMentorCert.pdf?dl=0 (only the training portion is required), and
2) Your certificate of training issued at the time of the training, and
3) The syllabus/agenda from your mediator training, and
4) A resume/curriculum vitae if you have one. If you do not have one, a written summary (2 pages or less) of your experience and interest.

Have you already taken part in a mentored/supervised mediation experience, too?
- Yes, with MetroMediation
- Yes, with another program/organization
- No, I have not
If you answered "No," please skip to the "Last Questions!" section below. If you answered "Yes," please continue here...
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END date of your mentoring/supervised experience (approximate)
If you took part in a mentored/supervised experience outside MetroMediation, please indicate: NAME of program/organization conducting the mentoring/supervision, NAME of mentor(s), PHONE & EMAIL CONTACT INFO for mentor who can provide a reference, if available.
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Number of months you received mentoring/supervision (approximate)
Total hours you OBSERVED mediations (approximate)
Total hours you CO-MEDIATED (approximate)
Total hours you MEDIATED SOLO (approximate)
SOLO hours observed by mentor/supervisor (approximate)

Any additional mediation training or experience you would like to describe? If so, please include: NAME of program/organization, CASE TYPE(S), approximate number of hours that you CO-MEDIATED and that you MEDIATED SOLO, and any other comments you would like to add. Please also use this box for general comments or questions.
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What language(s) do you speak?
How did you learn about MetroMediation's training programs?
- Website
- Email notice
- Friend or colleague
- Print notice
- Other (please specify in comment box below)

Item Qty. Max Limit Price

Item	Qty.	Max Limit	Price
By prior arrangement with MetroMediation Please fill in the dollar amount of your payment in the "quantity" box. (For example, to pay $500 now, type "500" in the box.)		99999	$1.00 each

Please fill in the dollar amount of your payment in the "quantity" box. (For example, to pay $500 now, type "500" in the box.)

99999

$1.00 each