1 Start 2 Payment 3 Complete PLEASE READ the following information BEFORE you complete the application form: ► MCFM offers individual memberships only. Find out more about MCFM memberships ► Dues: Premium membership (with online Referral List and profile): $190 per year Basic membership: $90 per year. ► New Members: Your membership will be activated upon receipt of your payment. MCFM will send an email from info@MCFM.org containing your account and login information for the MCFM website. You must log in to your member account to make changes to the information on this form and to view members-only content. ► Renewing Members: Your latest member information should be prefilled in the form below. If not, STOP. Please follow the special link from your renewal reminder email OR log in to your member account and click "Renew Now" under "Member Status" in the right sidebar. Your member information will now be prefilled in the form below, and your payment will be properly applied to your member account. If your membership expired before October 1, 2015, please email the MCFM Administrator for assistance. ► Payment: MCFM accepts online credit card payments only (Visa/MasterCard/Discover/Amex). After you submit your application, you will be taken to our payment page. Enter your billing name and billing address as they appear on your credit card statement. If there is a mismatch, MCFM's credit card processor will decline your payment. MCFM does not process offline transactions. Press the "Submit" button ONCE on the payment page and wait. You will receive an onscreen confirmation when your payment has been processed. QUESTIONS? Email the MCFM Administrator PLEASE NOTE: All fields marked with an * in the form below are required. Member Contact Info This section is just for MCFM to contact you. You can enter your address for the Member Directory and the Referral Directory in the "Online Directories: Office Locations" section below. First Name * DO NOT include titles in this field (e.g., "Dr."). Nickname: What are you called by your friends and colleagues? (For example: "Bob" for Robert, "Liz" for Elizabeth). If you go by your first name as it appears above, please reenter it below. Nickname * Last Name * DO NOT include degrees or certifications in this field (e.g., "Esq.," "Ed.D.," "LICSW"). Phone Number * Email * Mailing Address Please enter your BUSINESS MAILING ADDRESS below. MCFM will use this address for official purposes only. Business Name Business Street Address * City * State/Province * Zip Code * Enter 5-digit Zip Code. Mailing Lists Mailing Lists MCFM will notify you by email of all MCFM activities and events and will forward professional news and events from an approved list of nonprofit third parties. Both of these lists are low-volume and will help keep you informed. You may unsubscribe from either group at any time by logging in to your member account or by clicking the "unsubscribe" link at the end of any MCFM email. NEW MEMBERS: MCFM encourages you to check BOTH mailing lists. Third Party Announcements MCFM Member Announcements Online Directories: Office Locations Physical Office Locations: All MCFM members may list one office location (address and phone number) in the online Member Directory. Premium members may list up to two locations in the online Referral Directory. Business email addresses and website addresses are published for Premium members only. All members should complete Physical Office Location #1. Premium members with a second office should also complete Physical Office Location #2. Physical Office Location #1 Street Address City State Zip Code Enter 5-digit Zip Code. Phone Number Email PREMIUM MEMBERS ONLY Website PREMIUM MEMBERS ONLY-- Please include http:// or https:// in your website address: Physical Office Location #2PREMIUM MEMBERS ONLY Street Address City State/Province Zip Code Enter 5-digit Zip Code. Phone Number Online Directories: All members are included in the Member Directory. Premium members are included in the Referral Directory. If, for any reason, you would prefer NOT to be included in these directories, please select "No" below. Display in Member Directory? Yes No All Members are displayed in the Member Directory unless this is turned off. Display in Referral Directory? Yes No This affects Premium members only and their inclusion in the Referral Directory. Membership Type * Basic Membership - $90 Premium Membership - $190 Membership Certification NOTE: You must complete the following certification section in order to join MCFM or to renew with MCFM. You are in good standing in your profession. You will uphold MCFM's Standards of Practice. Review the MCFM Standards You will hold MCFM harmless from claims arising from your mediation practice, including any errors or omissions in MCFM's directories. Questions? Contact us. Self Certification * I agree I am in good standing, will uphold MCFM's standards and will hold MCFM harmless from claims. Premium CertificationPremium Members must also certify that they have completed 30 hours of mediation training AND are currently practicing mediation professionally. Premium Certification Statement I certify I've completed 30 hours of mediator training AND am currently practicing mediation in my practice. Premium Profile NEW MEMBERS: The fields below are included in your online Referral directory listing. You don't have to enter all your information now -- you can log back in to your member account after your membership is activated to make changes. To get started, MCFM recommends you enter your name as you wish it to appear in the directory and you check off your Practice Areas and the counties where you offer services. Then be sure to log in later and complete your profile! RENEWING MEMBERS: Please take a moment to review your online Referral directory listing below and update it as needed. Practice Details Directory Name * This field is required. Enter your name (including titles/certifications) as you would like it to appear in your Referral Directory listing, e.g., "Jane Doe, LICSW"; "John Doe, Esq." Tagline This is a short text field that displays in your directory listing. Give highlights of your practice, experience, expertise and maybe something personal (e.g., "enjoys sailing"). Areas of Practice Select all of the mediation areas in which you practice: Divorce Mediation Child Custody Mediation Estate Planning & Probate Mediation Family Business Mediation Pre-Nuptial & Post-Nuptial Agreements Marriage Mediation Cohabitation & Non-Marital Parenting Elder Mediation Mediation for Same Sex Couples Parent Coordination Counties Select all the counties you are available to work in: Barnstable Berkshire Bristol Dukes Essex Franklin Hampden Hampshire Middlesex Nantucket Norfolk Plymouth Suffolk Worcester Practice Details Enter general information about your practice here. Note that generic information about where you practice (county), specialties, degrees and experience are best entered in other fields. You can enter a maximum of 3000 characters. Regional Information Provide specific details about where and when you work, if applicable. Fee Information Degrees and Experience Professional Memberships
