Name *

Please note that your family name and other names should be the same as the official names on your passport or birth certificate.

First Name

Last Name

I confirm that I am a New Zealand Citizen and that I have a valid passport for travel *

Yes

No

Ethnicity *

Samoan

Cook Islander

Niuean

Fijian

Papua New Guinean

Tuvaluan

Tokelauan

Tongan

Rotuman

Ni Van

Other

Date of Birth *

dd/mm/yyyy

MM

DD

YYYY

Gender *

Male

Female

Other

Region of Residence

Northland

Waikato

Bay of Plenty

Hawkes Bay

Manawatu- - Whanganui

Nelson

Canterbury

Otago

Southland

Other

Please provide us with your contact details in NZ and your next of kin *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please provide us with your contact details in NZ and your next of kin *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Please provide us with a number that we can contact you on to discuss your application.

Country

(###)

###

####

Declaration *

Tick all boxes

confirm that all information provided is true and complete.

I am committed to representing the Pacific region and Aotearoa with integrity and respect.

agree to participate in post-programme reflection and storytelling.

I understand that if selected, I will need to be available