Mediator Panelist Application Template Page 5
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6Superior Court of California, County of Sacramento
Mediation
Criminal or disciplinary actions will not automatically bar you from inclusion in the program. Each case
is considered individually. Failure to list criminal convictions or professional disciplinary actions taken
against you, however, will result in automatic removal from the program.
Please provide any other pertinent information reflecting positively or adversely on you which you believe
should be disclosed in connection with your possible appointment as a court mediator:
TO ALL APPLICANTS:
If selected to serve on the Court’s Mediation Panel, I agree to the following:
1.
Provide three hours of pro-bono mediation. In the event the parties wish to continue beyond three
hours, the parties will be responsible for compensating the neutral at his/her agreed-upon rates.
The court’s mediator panel list will include mediator hourly rates. For this purpose, please
provide your hourly rate: _________________________.
2.
Comply with the General Rules Relating to Mediation of Civil Cases contained in California
Rules of Court Sections 10.781 through 3.810 et seq.
3.
Disclose all fees to counsel and parties.
4.
Disclose any potential conflicts of interest.
5.
Be available to conduct mediation sessions in Sacramento County if requested by the parties.
6.
Conduct two court mediation sessions in a six month period with the option to mediate additional
cases if interested.
7.
Complete and return the Statement of Agreement or Non-agreement form to the court within ten
days from the date the mediation is held.
8.
Complete and return, and encourage mediation participants to complete and return, evaluation
forms within 10 days following the final mediation session.
9.
Report to the ADR Administrator any criminal convictions in which I am involved in or become
involved in as well as any disciplinary action taken against me by any state, federal or professional
licensing board and/or agency.
10.
Be available for observation by ADR staff with the consent of counsel and parties.
11.
Attend training sessions sponsored by the court as may be required.
12.
Not to exploit my service as a court mediator by including reference to such position in any
advertising, or on any letterhead, business card, or telephone listing (listing on a curricula vitae is
permissible)
APPLICANT’S INITIALS: __________
Mediation Panelist Application
CV-E-MED-163 (Revised June 17, 2013)
Page 5 of 6
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