Registration
County/Family Mediation Enrollment Form

* indicates required fields 
  *Name (Last, First):
  *Address:
  *E-Mail:
  *Phone:
  Class Date:
  Educational Degrees:
  Professional Licenses:
  Special Request (ADA, dietary):
  *Payment with check:  Yes
 No
  Payment with Visa or Mastercard:  Visa
 Mastercard
  Credit Card Number:
  Name on credit card as it appears:
  Credit card expiration date:
  Mailing address for credit card:
  Questions or comments:

Please click on the Submit button to submit the form details.
 

Alternative Dispute Resolution, LLC, P.O. Box 4446, Orlando, Florida 32802-4446
Direct Phone (407) 538-5509, Fax (407) 926-6224, E-Mail at: sw@altdispute.com 

 

 

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