2024 Scholarship Application - Diversity, Culture and Social Justice in Psychedelics

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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? *

Annual Income (for US residents only):

25,000 or less

25,000 to 75,000

75,000 to 150,000

over 150,000

Clear selection

Is there anything else you would like for us to know about your request for financial support? *

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

30% off

50% off

90% off

Please write a brief statement (250 words max) describing your interest in attending the workshop and why you should receive a scholarship ticket. Describe how a scholarship for this course will support your commitment to access, equity and justice. Please reference benefit for specific communities you interact with. *

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