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					 Maine Rostered Guardian ad litem Professional Continuing Education Requirement and
                           Annual Reporting Form 2012
 Failure to comply with Rule II (2) (E) of The Rules for Guardians ad litem, will result in removal from the Guardian Roster

NAME:
                                    Please print clearly
ADDRESS:

* Is this an address change?   No       Yes If your address has changed, please indicate any changes in courts you will serve.

PHONE:                                                     EMAIL:
                                                           * Is this a new email address?   No   Yes

Title __________________ Professional License(s) held:                                       Number #:
Expiration date:

    I.       Between July 1, 2011 and June 30, 2012, did you attend:

                            (The programs below were pre-approved for GAL continuing education credits)
       (Check all that apply)
    a.    GAL CORE training 10/17 to 10/21/11
    b.    Webinar on Rules & Standards of Practice for Guardians ad litem in Maine (Muskie School) 8/17/11 (1.5) Credits
    c.    Creating a More Family-Centered Court (Probate Judge Longley) 9/21/11 (2.0) Credits
    d.    Using Collaborative Problem Solving to Co-Parent the Special Needs Child (Barbara Baum Freethy, M.Ed.) 9/26/11
          (2.0) Credits
    e.    Regional Court Forums on “What’s New in Child Protection?” (Family Division Regional Forums) 10/3/11 through
          10/6/11 (3.0) Credits Presque Isle; Bangor; Augusta; Lewiston; Portland.
    f.    Domestic Violence (York County Bar Association) Ramada Inn, Saco 10/26/11 (3.0) Credits
    g.    Step-Family Dynamics and Child Custody Disputes (Kids First) Harraseeket Inn, Freeport 11/10/11 (6.0) Credits
    h.    Co-Parenting with Addiction (Kids First) Portland 11/14/11 (2.0) Credits
    i.    2012 GAL Appointments in District Court (Maine State Bar Association) Hilton Garden Inn, Freeport 1/13/12 (6.5)
          Credits.
    j.    Access to Justice Symposium: Serving the Legal Needs of Maine’s Growing Elderly and Immigrant Populations
          (Justice Action Group)      Portland 1/25/12: 3-5 p.m. (2.0) Credits; and/or 1/26/12: 8:30 a.m.- 4:45 p.m.
          (5.5) Credits
    k.    The GAL’s Role in PR&R in Cases When Domestic Violence is Present (Muskie School of Public Service) Muskie
          School, UMO)        4/9/12. 6.0 Credits; or    or 4/11/12 (6.0) Credits
    l.    Part 1: Assisting Parenting Capacity Evaluations—Role of the GAL (Muskie School of Public Service) WEBINAR
          4/16/12 (1.0) Credit
    m.    Separation, Divorce and the Very Young Child (Kids First) Portland 4/23/12 (2.0) Credits
    n.    Part 2: Using and Assessing Parenting Capacity Evaluations—Role of the GAL (Muskie School of Public Service)
          4/26/12 (1.5) Credits
    o.    Early Experiences Matter: Effective Advocacy for Vulnerable Children & Families (Maine Judicial Branch Family
          Division) Marriott Sable Oaks, South Portland 5/3 & 5/4/12 (10.5) Credits
    p.    Making it Work: Tools for Creating Successful Parenting Plans (Maine Bar Association), Bangor 5/11/12 (6.25)
          Credits
    q.   Understanding the Drug Addicted Offender (Maine Alliance for Drug Treatment) Courts, Bates College, Lewiston
          06/15/2012 (3.0) Credits

    II.      Did you attend another training which you would like considered to fulfill your GAL continuing education requirement
             and which involved any of the following: Title 19-A or Title 22, dynamics of divorce and its effect on children, child
             development, the effects of trauma on children, substance abuse, relevant legal issues and processes, the duties and
             obligations of the Guardian as an agent of the court, or interviewing techniques?
                No.
                Yes. If you answer yes, you must complete the applicable section on the reverse page.


    III.     Did you attend a training approved by the Chief Judge at a reduced cost thereby agreeing to accept Title 19-A pro bono
             cases or agreeing to accept cases on a reduced fee basis?
                 No.
                                                                       1
                  Yes. If you answer yes and you have not previously submitted your pro bono docket information, you must complete
              the applicable section below.

    IV.       Since your date of rostering have you: 1) been removed, suspended, reprimanded or otherwise been the subject of any
              other discipline or sanction by a licensing board, professional neutral organization, other professional organization, court
              or governmental tribunal; or 2) had a written complaint filed against your professional license; or 3) been convicted of a
              crime; or 4) been the subject of any substantiated DHHS case; or 5) had a written complaint filed with regard to your role
              as a Guardian ad litem?
                   No.
                   Yes. If you answer yes, you must complete the applicable section below.

                              I am not completing this form, because I no longer wish to serve as a Guardian.
                                           Please remove my name from the GAL Roster.
,

    I. Title of Professional Education Program(s) attended between July 1, 2011 – June 30, 2012.

    A.

          Brief summary of relevant content:



          Program sponsor                                                   Date:                    Hours:
               Use additional sheets, if necessary.

    II. Title 19-A Pro bono/Reduced fee cases:

    Name of Case                                                         Name of Case
    Court location and docket number                                     Court location and docket number
    Type of appointment: pro bono           reduced fee                  Type of appointment: pro bono          reduced fee

    III. Please provide full details of any discipline or other sanction by any licensing board, professional organization, or court,
    governmental tribunal:

    (Use additional sheets if necessary).

    IV. Please provide full details of any criminal convictions:

    (Use additional sheets if necessary).

    V. Please provide full details of any matter in which you were the subject of a substantiated DHHS case:

    (Use additional sheets if necessary).

    VI. Please provide full details of any Guardian ad litem complaint you were subject to.


I certify that the above information is true,


Date                                                            Signature

                                  Please return this completed form by June 30, 2012
                                 To: Administrative Office of the Courts/Family Division
                                   171 State House Station, Augusta, ME 04333-0171



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