Pro Bono Attorney Enrollment Form

I am interested in helping with the court’s Pro Bono Care Program.

Name:  _________________________________________________Date:__________

Address:  _____________________________________________________________

City, State, Zip:  _______________________________________________________

Office phone: __________________________________________________________

Office FAX: ___________________________________________________________

Email: ________________________________________________________________

Foreign languages spoken _________________________________________________

I would like to register for malpractice coverage with the State Legal Expense Fund –
       [  ] Yes [  ] No

I practice in the follow areas of the law (check as many as appropriate):

•	Adoptions
•	Bankruptcy
•	Child custody
•	Child support
•	Civil litigation
•	Civil rights
•	Consumer rights
•	Contracts
•	Credit access
•	Debt collection
•	Disability claims or rights
•	Domestic relations
•	Elder abuse
•	Guardianships
•	Health issues
•	Housing issues
•	Immigration
•	Juvenile law
•	Medicaid benefits
•	Mental health issues
•	Nursing home issues
•	Powers of attorney
•	Public assistance
•	Public utilities
•	Real estate
•	Spousal abuse
•	Torts/Personal Injury
•	Taxation
•	Unemployment claims
•	Wills, probate & estates
•	Workman’s comp

•	Other: ______________________________________________________
•	Other: ______________________________________________________
•	Other: ______________________________________________________

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•	I am willing to advise and represent some less fortunate persons who may be referred by the Court’s Pro Bono Care program.  I may decline any matter.

•	I am willing to consult with or mentor other attorneys in the Pro Bono program from my special knowledge and experience.

•	I am trained as a mediator and am willing to provide mediation services.

Return this sign up form to:

{Insert contact information}
.