RETURNING MEMBERS - Annual Renewal Due by FEBRUARY 28

Payment Choice *

Mail Check to: Mediation Council of Illinois, PO Box 704, 109 Symonds Drive, Hinsdale, IL 60521

Request PayPal Invoice Email (sent by MCI Administrative Assistant)

Pay through PayPal Link (available after submission)

Please select a payment option. If you choose the Check option or the PayPal Invoice option, you can ignore the PayPal link after your form submission.

Prices *

Regular Member (voting) $75.00

Referral List Member with Website Listed (additional designation - Reg. Membership fee included as required) (voting) $175.00

Referral List Member No Website Listed (additional designation - Reg.Membership fee included as required) (voting) $150.00

Associate Member (non-voting) $50.00

Student Member (non-voting) $25.00

Friend of the Mediation Council (non-voting) $25.00

Emeritus Member(non-voting)No Annual Fee

REFERRAL LIST APPLICANTS ONLY with Website Listing A benefit we offer for MCI Referral List Members is to post your website address with your MCI Referral Directory listing. To have your website link posted with your MCI Referral member listing, MCI requires that you provide a link back to the MCI website on your website at all times. The fee for posting your website on the MCI website is a $25.00 annual fee included in your selection above. (Please note, that there will be no pro-ration of this fee and renewal of this fee will coincide annually with your Referral membership renewal.)

Website

1. Please provide the following information. Referral members please provide information as you want it to appear on the web site

Name *

Organization or Firm Name

Address *

City *

State *

Zip-Code *

Additional Addresses

Please select county or counties that are within 5 miles to your office address(es)

Phone (Home)

Phone (Cell)

Phone (Work)

Fax

E-mail *

Profession

Authorization *

I hereby authorize the Mediation Council of Illinois to utilize the information provided above at the discretion of MCI

2. Please submit documentation for MCI’’s ANNUAL CONTINUING EDUCATION REQUIREMENT Regular Member (3 credits), Associate (3 credits), and Referral Applicants (6 credits).

Date *

Month

Day

Year

Provider *

Description *

Date

Month

Day

Year

Provider

Description

Date

Month

Day

Year

Provider

Description

3. REQUIRED FOR REFERRAL APPLICANTS ONLY: Please provide the following information for your Mediator Professional Liability Insurance. Please email or upload 1) a copy of the current declarations page from your policy, and (2) any additional documentation that is necessary to show that your policy expressly covers you for mediation and the effective dates of the policy. (Please note that some therapists’ and counselors’ policies do not expressly cover mediation and will not satisfy this requirement.) You are responsible for providing updated policy information should your policy expire prior to the term of your membership.

Effective Dates

Carrier

Description of Coverage Stated in Policy

4. In the past year, have there been any changes in your status with respect to verification, licensure, or required memberships in organizations related to your professional endeavors?

No, there have not been changes

Yes, there have been changes, (please describe)

Changes Yes, there have been changes, (please describe)

5. REGULAR and REFERRAL LIST MEMBERSHIP APPLICANT: Provide supporting documentation for continuing education requirement and a copy of your current licenses, certification, or membership card by email or upload.

6. Are you willing to be included on a mediation Council of Illinois list of pro-Bono mediators? If yes please list the how many you are willing to do next year if not please leave field blank.

pro-Bono Clients

please list the number of pro_Bono referrals you would be willing to accept

7. REQUIRED FOR ALL MEMBERS. Check all types of family mediation services offered.

8. What type of mediation services do you provide other than family mediation? Please describe your non-family mediation services and include your experience in terms of training, number of mediation's conducted, years of experience, etc.

7a

9 *

	YES	NO
9. Your name will be automatically included in MCI mailings and online communications. If you do not want to be included in these lists please designate.	9. Your name will be automatically included in MCI mailings and online communications. If you do not want to be included in these lists please designate. - YES	9. Your name will be automatically included in MCI mailings and online communications. If you do not want to be included in these lists please designate. - NO

Certification 1 *

I HEREBY VERIFY THAT ALL OF THE INFORMATION ON THIS APPLICATION, AND ANY INFORMATION I HAVE SUBMITTED TO THE MEDIATION COUNCIL IN SUPPORT OF MY APPLICATION FOR MEMBERSHIP, IS TRUE AND ACCURATE. I ALSO VERIFY THAT I AM A MEMBER IN GOOD STANDING IN MY PROFESSION OF ORIGIN, THAT I HAVE READ AND AGREE TO ABIDE BY MCI’S “STANDARDS OF PRACTICE FOR MEDIATORS”. I ACKNOWLEDGE AND AGREE THAT MY MEMBERSHIP IN THE MEDIATION COUNCIL CAN BE TERMINATED AT THE DISCRETION OF THE BOARD OF DIRECTORS FOR NOT ABIDING BY THOSE STANDARDS OF PRACTICE AND MCI ETHICS PROCEDURES IN SUPPORT THEREOF OR NON-COMPLIANCE WITH MCI MEMBERSHIP REQUIREMENTS AT THE DISCRETION OF THE MCI BOARD OF DIRECTORS.

REQUIRED FOR REFERRAL APPLICANTS ONLY:

Certification 2

I HEREBY VERIFY AND AGREE THAT IF I AM INCLUDED IN THE MEDIATION COUNCIL REFERRAL DIRECTORY, I WILL CONTINOUSLY MAINTAIN MEDIATOR MALPRACTIC COVERAGE FOR ALL AREAS OF MEDIATION THAT I PRACTICE AND FOR THE ENTIRE TIME THAT I AM INCLUDED IN THE REFERRAL DIRECTORY.

I HEREBY VERIFY AND AGREE THAT IF I AM INCLUDED IN THE MEDIATION COUNCIL REFERRAL DIRECTORY, THE DIRECTORY INFORMATION RELATED TO ME MAY BE DISTRIBUTED AT THE DISCRETION OF THE BOARD OF DIRECTORS OF THE MEDIATION COUNCIL, THAT THAT MAY BE IN HARD COPY, ORALLY IN RESPONSE TO TELEPHONE INQUIRIES, THROUGH THE MEDIATION COUNCIL WEB PAGE OR OTHERWISE. I HEREBY RELEASE THE MEDIATION COUNCIL OF ILLINOIS FROM ANY CLAIM I MAY HAVE, NOW OR IN THE FUTURE, IN THAT REGARD.

I HEREBY VERIFY THAT I SUCCESSFULLY COMPLETED 5 FAMILY MEDIATIONS RESULTING IN AGREEMENT ON ALL ISSUES PRESENTED.

Signature *

Please Type Full Name

Today's Date *

Month

Day

Year

Submit Below. Please review membership fee amount before submitting if using paypal on the next page.