Restorative Justice Program – Long Beach City Prosecutor Doug Haubert

Date of Application

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email

Best way to contact you?

Home
Cell
Email

Date of Birth

Place of employment/School attended (if retired or unemployed, please list previous employment)

Position or Title/Year

Current and/or previous community involvement?

Do you speak any foreign languages? Please list:

How did you learn about Neighborhood the Restorative Justice Program?

Why would you like to participate in Neighborhood RJP?

What qualities do you have that would make you a good Neighborhood RJP Panelist / Facilitator? (You may include special skill or strengths you believe are applicable)

What do you hope to gain or learn by being a Neighborhood Courts Panelist / Facilitator?

Please list any formal training you have received in mediation, facilitation or other related conflict resolution processes including name of training provider and dates.

Please describe your mediation, facilitation or other related experience, including types of mediation and number of years.

Have you ever had adverse experience or contact with a law enforcement agency of the court system? If so, please explain:

What are your interests and hobbies?

Do you follow sources that focus on the criminal justice system such as novels, blogs, the internet, newspapers, TV, or radio? If so, whatsources?

Please describe your experiences with the criminal justice system?

Have you ever had any adverse experiences or contact with a law enforcement agency or the court system? If so, please explain:

Have you ever been convicted of a Yes No crime?

No
Yes

If yes, please explain:

When are you available to volunteer?

Are there any days, hours, or times of the year you are NOT available to volunteer?

Do you have any special needs requiring accommodation?

No
Yes

If YES, how can we assist?

References – Please list 2 contacts familiar with your work ethic and capabilities (No relatives please)

First

Last

Relationship to you?

Phone

References – Contact 2

First

Last

Relationship to you?

Phone