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Mediator Application Form

Please fill out the following application. Contact with any questions.

Contact Information

Format: Last, First M.I.

Bar Admissions

Are you a member in good standing in each jurisdiction where admitted to practice law?:

ADR Experience

Summarize your ADR experience, particularly in the last five years:
Within the past three years, list the number of sessions you participated in as:

ADR Training

Summarize your ADR training. Include Course Provider, Course Content, Date and No. CME Hours:
Total No. of CME credit hours received within the preceding two years:
State whether you are an approved mediator for civil cases pursuant to the rules adopted by the Kansas Supreme Court:

Legal Experience

Summarize your legal or other professional experience (including teaching), particularly in the past five years:
Please list the number of years you've spent in active litigation:
Within the past five years, list your percentage of practice representing:
Please describe any other experience you have litigating:
Please describe your legal and professional education (Include degree, school, year received):
Describe any other relevant information (e.g. publications, professional affiliations, awards, additional experience or skills):

Fee Structure

Describe your mediation fee structure:


This section will not be made publicly available.

I consent to public disclosure, including on the court's internet site, of the information above. (The court will post your profile only if you are accepted for the List of Mediators):
Have you ever:
  1. been part of any civil, criminal or administrative proceeding charging you with conduct involving dishonesty, unethical conduct or commission of a crime? or
  2. been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group, excluding sanctions in an amount less than $1,000, imposed against you in a civil proceeding?
I have read the court's ADR plan which is set forth in D. Kan. Rule 16.3. I will provide the disclosures required by D. Kan. Rule 16. 3(g).
I agree to participate periodically in court-approved ADR orientation or refresher training
I agree to permit participants in the mediation sessions I conduct to give feedback to the court about how the process was conducted
I agree to submit reports upon conclusion of the mediation
If requested by the court, I agree to serve as a mediator on a pro bono basis or, in the court's discretion, at a reduced fee in two cases per year
Use this area to provide any additional information for your application, if needed:

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All applications are screened for accuracy and qualifications before being posted. Submitting this application does not guarantee approval.