Chacruna Institute's Queering Psychedelics II Conference

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Chacruna Institute's Queering Psychedelics II Conference - Scholarship Application

This is a scholarship application for Chacruna Institute's Queering Psychedelics II Conference which will be taking place in-person in the Bay Area at the Brava Theater on April 22-23, 2023.

First Name *

Last Name *

Email *

Phone Number *

City, State *

Birthdate *

YYYY

Gender *

Ethnicity *

Asian

Black/African American

Hispanic/Latinx

Native American

Pacific Islander

SWANA

White/Caucasian

Additional Identity (fill in below)

Prefer not to answer

Additional Identity

Affiliation / Profession *

Are you a student? *

Yes

Name of school/program? *

What scholarship percentage would you need to be able to attend this course? *

30% off

50% off

90% off

Other:

Please write a brief statement (250 words max) describing your interest in attending the conference and why you should receive a scholarship ticket. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Chacruna Institute for Psychedelic Plant Medicines. Report Abuse

Forms