Name *

First Name

Last Name

Address *

Address 1

Address 2

City

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Zip/Postal Code

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Which courses or retreats are you seeking a scholarship for? *

Please select all that you are interested in attending.

Arizona Ketamine Retreat

South America Retreat

The River Course

Online Workshops: Sacred Ceremony in Psychedelic Therapy

What percentage of assistance would make it possible for you to attend this course or retreat? *

30%

50%

100%

Annual Income (for US residents only):

$25,000 or less

$25,000 to $75,000

$75,000 to $150,000

Over $150,000