IDAHO SUPREME COURT 451 WEST STATE STREET
P.O. BOX 83720 BOISE, IDAHO  83720-0101

APPLICATION FOR REGISTRATION ON THE IDAHO SUPREME COURT'S ROSTER OF CHILD CUSTODY MEDIATORS
Idaho Rules of Family Law Procedure Rule 602

Part 1– General Information

1.	Qualifications for Placement on the Roster of Registered Mediators

To be placed on the Supreme Court's roster of registered child custody mediators, the mediator must have at least one of the following professional credentials:

A.	The applicant is recognized by Idaho Mediation Association as a Certified Professional Mediator (CPM), or maintains membership in the Association for Conflict Resolution at the advanced practitioner level or other national organizations with equivalent standards for membership.

B.	The applicant is a member of one of the following: the Idaho Judiciary; licensed member of the Idaho State Bar Association; licensed psychologist; licensed professional counselor; licensed clinical professional counselor; licensed master social worker; licensed clinical or independent practice social worker; licensed marriage and family therapist; certified school counselor; or certified school psychologist.

C.	The applicant possesses a bachelor’s degree.

2.	Supporting Documentation

An applicant must submit the following to be placed on the approved roster of child custody mediators maintained by  the Supreme Court:

A.	The attached application;
AND
B.	An affidavit of compliance executed by the applicant attesting that the applicant has fulfilled the requirements for registration;
AND
C.	If the applicant is submitting an application on the basis of Idaho Mediation Association certified professional mediator (CPM) credentials, or membership in a national mediation organization, as set out in 1A above (Category I on the application), a copy of the current membership certificate, together with proof of the required sixty (60) hours of mediation training, 20 of which must be in the field of child custody mediation within the last two (2) years;
OR
D.	If the applicant is submitting an application on the basis of holding one of the enumerated licenses designated in 1B above (Category II on the application), a copy
A.	
of the Idaho license or certificate, together with proof of the required forty (40) hours of mediation training, 20 of which must be in the field of child custody mediation within the last two (2) years; or
OR
E.	If the applicant is submitting an application on the basis of a college degree as set out in 1C above (Category III on the application), a certified copy of the applicant's degree, or in the alternative, a certified transcript of the applicant's college work at an accredited college or university that states the earned degree, together with proof of the required sixty (60) hours of mediation training, 20 of which must be in the field of child custody mediation within the last two (2) years.

3.	To qualify for credit, training shall be approved and/or provided by an accredited college or university, the Idaho Mediation Association, Association for Conflict Resolution, Association of Family and Conciliation Courts, The Idaho State Bar, or the Idaho Supreme Court, Administrative Office of the Courts.

4.	Continuing Education to Remain on the Supreme Court Roster

A.	In order for a person to remain on the Supreme Court's roster of child custody mediators, the mediator must provide a copy of a current professional license and acquire a minimum of thirty hours of additional child custody mediation training every three years. The three-year reporting period begins on the next July 1st after the mediator is placed on the roster of mediators. The mediator must file proof of compliance with this requirement with the Administrative Office of the Courts by July 1 of the year the continuing education is due. The additional training shall include a minimum of two (2) hours of mediation ethics, together with one or more of the following areas:

1)	conflict resolution theory
2)	psychological issues in separation, divorce, and family dynamics;
3)	domestic violence;
4)	issues and needs of children;
5)	mediation process and techniques;
6)	family law, including custody and support,
7)	mediation ethics – a minimum of 2 hours
1)	
Idaho Supreme Court

APPLICATION FOR REGISTRATION ON THE IDAHO SUPREME COURT'S ROSTER OF CHILD CUSTODY MEDIATORS

Part 2 – Application Form

Name:  	

Organization:  	

Mailing Address:  	

City:	County:	State:	Zip:  	

Telephone:	Fax:	Email:  	

Counties where you are willing to conduct mediation:  	

Note: Unless otherwise requested, the information you furnish above will be used in all correspondence with you and will be posted on the public roster of mediators.

INSTRUCTIONS

Application based on: (please check one)

Category A: The applicant is recognized by Idaho Mediation Association as a Certified Professional Mediator (CPM), or membership in the Association for Conflict Resolution at the advanced practitioner level or other national organizations with equivalent standards for membership., and has a minimum of sixty (60) hours of mediation training within the last two (2) years, twenty (20) of which must be in the field of child custody mediation. Complete Sections A, D, and E.

Category B: Applicant is a member of one of the following: the Idaho Judiciary; licensed member of the Idaho State Bar Association; licensed psychologist; licensed professional counselor; licensed clinical professional counselor; licensed master social worker; licensed clinical or independent practice social worker; licensed marriage and family therapist; certified school counselor; or certified school psychologist, and has a minimum of forty (40) hours of mediation training within the last two (2) years, twenty (20) of which must be in the field of child custody mediation training.  Complete Sections B, D, and E.

Category C: Applicant possesses a bachelor's or higher degree and has a minimum of sixty (60) hours of mediation training within the past two (2) years, twenty (20) of which must be in the field of child custody mediation. Complete Sections C, D, and E

SECTION A:  The applicant is recognized by Idaho Mediation Association as a Certified Professional Mediator (CPM), or membership in the Association for Conflict Resolution at the advanced practitioner level or other national organizations with equivalent standards for membership. (Please submit copy of membership certificate(s).

Organization: 	

Address:  	

Type of Membership:  	

Membership Expires:  	

Organization: 	

Address:  	

Type of Membership:  	

Membership Expires:  	

SECTION B:  Members of the Idaho Judiciary and licensees of certain enumerated professions. (Submit copy of Idaho license(s) or certificate(s.)

Board or Certifying Organization: 	

Address:  	

Name of License or Certificate Held: 	

Membership Expires:  	

Board or Certifying Organization: 	

Address:  	

Name of License or Certificate Held: 	

Membership Expires:  	

SECTION C:  College Degree(s).   (Submit certified copy of transcripts and/or official copy of degree.)

Degree:  	

College/University Name:  	

Major:	Date Attained: 	

Specific Course Work in Mediation:  	

Degree:  	

College/University Name:  	

Major:	Date Attained: 	

Specific Course Work in Mediation:  	

SECTION D:  Mediation  Training. (Submit documentation /or each course taken.) NOTE: Courses sponsored by an accredited college or university do not require further approval. Training sessions conducted by other providers must be sponsored or approved by the Idaho Mediation Association, Association for Conflict Resolution, the Idaho State Bar, the Idaho Supreme Court, Administrative Office of the Courts, or be sponsored by the Association of Family Conciliation Courts as provided by Idaho Rules of Family Law Procedure Rule 602.

Sponsor:  	

Location:  	

Dates:	Hours: 	

Course Content:  	

Approved by:  	

Sponsor:  	

Location:  	

Dates:	Hours: 	

Course Content:  	

Approved by:  	

SECTION E:  Specialized Training in Child Custody Mediation. (Submit documentation for each course taken.)
NOTE: Courses sponsored by an accredited college or university do not require further approval. Training sessions conducted by other providers must be sponsored or approved by the Idaho Mediation Association,  Association for Conflict Resolution, the Idaho State Bar, the Idaho Supreme Court, Administrative Office of the Courts, or be sponsored by the Association of Family Conciliation Courts as provided by Idaho Rules
of Family Law Procedure Rule 602.

Sponsor:  	

Location:  	

Dates:	Hours: 	

Course Content:  	

Approved by:  	

Sponsor:  	

Location:  	

Dates:	Hours: 	

Course Content:  	

Approved by:  	

APPLICATION FOR REGISTRATION ON THE IDAHO SUPREME COURT'S ROSTER OF CHILD CUSTODY MEDIATORS

Applicant’s Signature:

 	  Date:  	

Please return the completed application with supporting documentation to:

Idaho Supreme Court Justice Services Division 451 West State Street PO Box 83720
Boise, ID 83720-0101

Idaho Supreme Court

APPLICATION FOR REGISTRATION ON THE IDAHO SUPREME COURT'S ROSTER OF CHILD CUSTODY MEDIATORS
Idaho Rules of Family Law Procedure Rule 602

AFFIDAVIT OF COMPLIANCE

State of	)

County of	)

To the Idaho Supreme Court:

I,	being first duly sworn, depose and say that:

I am the applicant who has signed this application for the placement of my name on the roster of registered child custody mediators maintained by the Idaho Supreme Court in accordance with Rule 602 of the Idaho Rules of Family Law Procedures. By signing this application, I certify that I have fulfilled the requirements set out in the particular category of professional   credentials   upon which I base this application.

I fully realize that the determination as to whether I am registered by the Idaho Supreme Court depends, in part, on the truthfulness and completeness of my answers set forth in this application, and the statements attached. To my knowledge, the answers and information which I have supplied in connection with this application are true and complete.

I have read and understand the contents of Rule 602 of the Idaho Rules of Family Law Procedures and Rule 507 of the Idaho Rules of Evidence, relating to the mediation of child custody and visitation disputes and mediator privilege, respectively, and I intend to conduct the mediation of child custody and visitation disputes in conformance with Idaho rules and statutes.

Applicant's Signature:	Date:  	

SUBSCRIBED AND SWORN TO before me, a Notary Public, in and for the State of	,

this	day of	, 20	.

NOTARY PUBLIC for the State of  	

Residing in	County

Commission expires