Domestic Relationsmediation Training

Domestic RelationsMediation Training

To register, please fill out both pages of this form and submit with payment.

Contact Information:

Last Name: First Name:
Street Address:
City: State: Zip Code:
Primary Phone: Secondary Phone: Email:

Payment Amount:

$995 (early registration) $1,045 (regular)

$495 (approved volunteerearly registration) $545 (volunteer)

$395 (early registration senior- 60 and over) $445 (senior)

Form of Payment:

Enclosed is my check payable to Wayne Mediation Center

Credit Card Type: Visa Mastercard Discover

Name as it appears on credit card______

Account Number:- - -

Exp:/

Mailing address for account (if different from above):

Street Address:
City: State: Zip Code:

I authorize the charge indicated above:

(authorized signature)

Reservation and Refund Policies/Agreementto Participate

The following information explains our reservation refund policy and your participation requirements:

There are a limited number of available slots for this training. You must pay in full before a spot can be reserved for you. If all of the slots are filled before your payment is processed, your spot will not be held;

In the event you cancel, your payment will be refunded in full as long as WMC is able to find someone to replace your spot. In the event WMC is not able to fill your spot, WMC will not refund to you your payment;

Participants must attend all training sessions and be on time. State Court rules do not allow us to provide a certificate of completion without 100% attendance. In addition, we also count on everyone in attendance in order to plan and assign role plays;

This training relies on a fishbowl/participatory environment. At any time you may be asked to write, talk, explain, question, answer, or perform any number of exercises designed to induce learning. If you have personal limitations (physical, mental, or otherwise) please alert the training staff so we may best accommodate your needs.

I have read the statements written above and I agree to the requirements listed therein.

______, 20__

(Applicant’s signature) (Date)

______

(Applicant’s printed name)

Garrison Place 19855 W. Outer Drive Suite 206 - East Bldg. Dearborn, MI. 48124 (313) 561-3500 (313) 561-3600 Fax