Practicum Application

Name*
First Last
Work Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
This information is not required, but helps us create a balanced group of mediators.
Age
Sex
Ethinicity
Fluent Languages
Please explain your interest in CMS*
Provide a summary of work and volunteer experience including any skills/experience that relate to your interests above (please attach resume).*
Upload Resume
Accepted file types: jpg, jpeg, pdf, doc, docx, txt.
Are you*
- employed
- self-employed
- job searching
- home employed
- student
- retired
- other
If other please explain
Please describe your flexibility and availability (example: day/night hours, days of the week, times of the year)*
Please describe your experience working with people of differing socio-economic, age, cultural, racial, religious, sexual orientation and special interest backgrounds*
Please describe any training experience relevant to conflict resolution*
Please list two references
Reference One
Name
First Last
Phone
Reference Two
Name
First Last
Phone
Do you have any special needs (physical, dietary, learning style, etc.)
Additional comments
A fee of $300 is due prior to the start of the program.
Application Fee
Price: $300.00
2017 Practicum Application Fee
Total
$0.00
Payment Method
- By Check
- PayPal
If paying by check, please bring in payment before training or mail to:

Community Mediation Services
300 E 17th St
Vancouver, WA 98663
Comments
This field is for validation purposes and should be left unchanged.

Please list two references