Coastal Sanctuary Collaborative Scholarship Application
This application is for individuals seeking scholarship support to participate in approved healing, education, or youth programs supported by Coastal Sanctuary Collaborative. Please complete the form as fully as you’re comfortable. All information is confidential and used solely for scholarship review.
Please complete the form as fully and honestly as possible. All information is kept confidential and is used solely to assess scholarship eligibility and allocation.
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Demographic Information
(This information is optional but helps us ensure equity in access to healing experiences.)
Race / Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latine (feel free to self-describe below)
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Multiracial / Two or More Races
Prefer not to answer
Prefer to self-describe below
Self-Describe Here:
Gender Identity
Please Select
Male
Female
Non-binary
Transgender Male/Trans Man
Transgender Female/Trans Woman
Genderqueer/Genderfluid
Agender
Two-Spirit
Prefer not to say
Prefer to self-describe (please write below)
Self-Describe Here:
Veteran Status
Yes
No
Prefer not to say
Household size / dependents (example: 5/2)
Caregiving Responsibilities
Pronouns
Program you're apply for:
*
Healing Journey: Ketamine
Healing Journey: Psilocybin
Veteran Support Services
The 360 Emergence Apprenticeship Scholarship
The 360 Youth/Kids Program Scholarship (parent/guardian application)
Holistic Health Support
Other (describe below)
Other (please describe)
About Your Desired Experience
Why are you seeking the program you are applying financial assistance for?
Have you chosen the healing center, program or facilitator?
Yes
No
If yes, please provide the name of the program, center, facilitator, teacher, healer, etc., website (if known), and date:
Financial Need
What is the total cost of the experience you want to engage in? (Please use USD$.
How much financial assistance are you requesting?
Briefly describe your financial need and why you are requesting support at this time:
Are you receiving any other sources of funding (e.g., GoFundMe, friends/family support, employer assistance, etc.)?
Yes
No
I can participate with partial funding
Yes
No
If yes, please describe:
Other Details
How did you hear about Coastal Sanctuary Collaborative?
Please Select
Dr. LeTa
Dr. Bean
Cindy Hill-Ford
A Facilitator
PsiloSafe
Search Engine
Social Medla
Email
Other
Tell us how you heard about us so we can thank them!
Would you be willing to share a written or anonymous testimonial (optional) after your journey to help others understand the impact of this work?
Yes
No
Maybe
DISCLOSURE, WAIVER, AND AFFIRMATION
Please read and affirm the following statements to complete your application. I understand that the Coastal Sanctuary Collaborative is a nonprofit organization offering financial assistance for individuals seeking legal healing experiences. The organization does not provide psychedelic substances, medical advice, or facilitation services. Waiver of Liability- I understand that participation in a healing journey, even in a legal setting, carries emotional, psychological, and physical risks. I agree to take full responsibility for my choice to engage in this experience and release Coastal Sanctuary Collaborative and its representatives from any liability related to my participation in a healing center or with a facilitator. Affirmation of Accuracy and Intent - I affirm that all the information provided in this application is true to the best of my knowledge. I understand that submitting false or misleading information may result in the forfeiture of scholarship consideration or awarded funds.
Consent
Adult Track: By submitting this application, I confirm that: I am at least 21 years old; I understand scholarships are awarded based on availability, financial need, and alignment with your mission.
Consent
Youth Track: By submitting this application, I confirm that I am the parent/legal guardian of the child that is seeking a scholarship; I understand scholarships are awarded based on availability, financial need, and alignment with your mission.
I have read, understood, and agree to the terms stated in this form.
*
Please verify that you are human
*
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