Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Preferred contact method: *

Email

Phone

Text

Best time to contact you: *

Day

Night

Business Phone:

(###)

###

####

Business Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If you have been convicted of a Felony or been under the limitations of a Protection Order, please indicate *

Note: Please explain any previous convictions or current protection orders. Provide dates and any restorative actions taken to resolve the issue. (We hold this information in strict confidence.)

No

Yes

Reference One

First Name

Last Name

Phone

(###)

###

####

Reference Two

First Name

Last Name

Phone

(###)

###

####

Effective participation in LSJI requires regular access and use of a computer with audio and video camera capabilities and high-speed Internet. LSJI also endeavors to provide course participants with experience in virtual meeting technology.

I have regular access to the Internet

I am able to use ZOOM and view files in Google, Microsoft Word, Microsoft Excel and PDF formats

Tuition payments can be by check or online, through www.lsji.org. A maximum of four (4) payments can be made which are due on the 10th of the month, beginning with January and continuing through April.

I would like to set up a tuition payment plan. (A Payment Plan form will be sent to you .)

I will pay in full now.

Scholarships from the LSJI organization may be requested up to a maximum of $400.00 and will depend on funds available. Please complete the information below to be considered for scholarship assistance. If a scholarship is awarded, the applicant is responsible for paying whatever remains on the tuition balance.

Yes, I wish to be considered for scholarship assistance

LSJI is a countywide program to educate and motivate community members interested in developing their professional skills and in learning more about issues affecting San Juan County. A core belief of LSJI is that the use of dialogue and other group-work tools can help people of all perspectives engage across their differences to effect meaningful and lasting change. Learning dialogue skills cannot be effective without the participation of ALL cohort members. I understand the above mission of LSJI. If selected, I will arrive on time to attend all sessions and will be both physically and mentally present, during the designated meeting dates and small group discussions between LSJI sessions and that attendance at the “Use of Self” Retreat is mandatory. I understand that no partners, children, pets or others are allowed at LSJI sessions or retreats, except service animals. (Partners and friends are welcome and encouraged to attend LSJI graduation.) I commit to making my best effort to maximize my learning and will support others in theirs. I will also support the LSJI program after graduation and attend alumni events when possible. I understand that an absence of two sessions (for any reason) will result in my removal from the rest of the course. Absences must be communicated to the Program Coordinator and participant is responsible for making up assignments. I understand that, in the interest of the class experience for all participants, a participant may be removed from the class if, in the opinion of the Executive and Curriculum Committee members of Leadership San Juan Islands, that participant’s conduct is not conducive to the work of the group. In such a case, no refunds will be given. I further understand that tuition is non-refundable in whole or in part, and I hereby acknowledge responsibility to arrange for full tuition payment.

First Name

Last Name