Membership Application – Child Specialist Date* Name* Practice Group, if applicable: Address Phone* Email* Website Address Degrees held & college/university: Degree* date rec’d* Degree date rec’d Professional license(s) and State where licensed: Years in child and family therapy: Describe your background and professional experience*: Collaborative divorce law training: date rec’d location of training: hours attended: instructor: Your business name, address and phone number will be published on CCDP website (https://charlottecollaborativedivorce.com) but not your email address (that is for sharing of information among members only). You will be forwarded any emails that originate from your profile page on the CCDP website. ANNUAL DUES: $150.00 PLEDGE I hereby apply for membership in the Charlotte Collaborative Divorce Professionals (“the Group”) and request that my name be included in the Group’s List of Collaborative Professionals. As a condition of continued membership, I certify that I will: Support the mission of the Group and the goals of collaborative practice, including, but not limited to: promote the resolution of conflicts outside of litigation through the collaborative team process; educate members, the profession and the community about collaborative law, and train professionals in the process. Comply with all rules, protocols and procedures of the Group as developed from time to time. Comply with the terms of every stipulation and agreement that I sign in the Collaborative Process. Complete 6 hours of training related to understanding the difference between a forensic and a clinical role Complete 6 hours of training related to understanding the impact of divorce upon children. Attend at least 50% of the Group meetings per year. If unforeseen circumstances prevent attendance at 50% of meetings, then I must perform 2 hours of time in committee work (e.g., websites, membership, program committee, publications/media), membership tasks approved by the Executive Board, or speaking engagements related to the Group’s mission. Timely pay annual Group membership dues. Signature Date* Δ