Apply – The Luke Center

Participate In The Pacific Program

Please complete the application form below. Required fields are marked with an asterisk (*). You will receive a confirmation email once your application has been submitted.

Personal Information

First Name *

Last Name *

Preferred Name

Pronouns

Contact Information

Email *

Phone *

Phone Type *

Mailing Information

Street Address *

Street Address Two

City *

State/Province

Zip / Postal Code *

Other

Are you vegan? *

Are you vegetarian? *

Other Dietary Restrictions

Do you have food allergies? *

Accessibility Needs

Background Information

Organization / Agency *

Current Title / Role *

Sponsor / Supervisor Name *

Sponsor / Supervisor Email *

Sponsor / Supervisor Phone *

Background Questions

How did you learn about the Pacific Program? *

Describe your leadership responsibilities *

Describe your experience working across sectors (Business, Non-Profit, Education...etc) *

Describe a professional challenge you'd like to discuss *

How will the program support your goals? *

Scholarship Information

Will a partial scholarship impact your ability to attend?

What amount of financial assistance are you requesting?

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