The Leela School of Awakening Application Form

The Leela School of Awakening Application Form
Psilocybin Facilitator Training Program Application

Personal Information
Please attach a photo of yourself here

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Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Gender
Are you a US Citizen?
Are you a resident of Oregon?
Have you served in the US military / armed services?
If you answered Yes to the previous question, were you Honorably Discharged?
Have you ever applied to The Leela School before?
If you answered Yes to the previous question, when?
Have you ever attended The Leela School before?
If you answered Yes to the previous question, what did you attend and when?
Please provide an Emergency Contact Person
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Education
Did you complete high school / secondary education?
If you answered Yes (or GED) to the previous question, please provide the year of graduation:
Please tell us if you have completed postsecondary education including the name, location and degree of received postsecondary education:
Are you fluent in the English language (written and spoken)?
Employment
Please describe your occupation:
Are you currently employed?
If you answered Yes to the previous question, please specify the name and contact details of your current employer:
Ethnicity
What is your National Origin?
Are you Hispanic or Latino?
Regardless of your answer to the prior question, please indicate how you identify yourself (select one or more):
Your Motivation
I am pursuing admission into the Leela School Psilocybin Facilitator Training Program for the following reason (choose one):
How did you discover our program?

Other
If you said Other above, please tell us where:
What inspired you to learn about and work with plant medicine?
What makes you resonate with our program in particular vs. other psilocybin facilitator programs?
What do you want to experience, learn and gain from this program?
What would be (a) good outcome(s) for you at the end of our time together? How would you recognize a good outcome - what would be the signposts?
Do you feel ready and capable to commit to the full duration of our program? What do you see as potential challenges to this commitment (if any)?
You are welcome to upload your CV/resume here (optional)

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Should be Empty:

The Leela School of Awakening Application Form

Psilocybin Facilitator Training Program Application

Please provide an Emergency Contact Person

Education

Employment

Ethnicity

Your Motivation