Student Practicum Registration

Student Practicum Registration
Please fill out the following practicum registration form, This Form is Required to attend the in-person training session.

Please Note: Students are responsible for their travel, transportation, lodging and food while attending Practicum
Practicum takes place at: Emerald Valley Holistic 1267 W 7th Ave Eugene OR

Emerald Valley Holistic is a OHA Licensed Service Center, all students must follow all OHA Service Center Rules while attending practicum
Will you be attending all 4 days of the in-person Practicum?

Yes I will be attending the Four day in Person Practicum Training
Which Training Session are you in? (For example Dec training session, Jan training session: Please make sure you put the correct session you are in as the practicum dates are different for different sessions)
Are you a currently enrolled student at Emerald Valley Institute?

YesNoNo, I am enrolled in a different training program
If you selected 'no' which training program are you in?
Please Note: Students will need to present their legal form of Identification and be checked in at the front entrance of Emerald Vallely Holistic upon arrival. There is parking available on the back lot of the building, only currently enrolled students particpating in practicum and staff are allowed to be on the premise (including the parking lot) during all practicum hours.
Which Program are You in (Please pick the correct program you are registered for ):

StandardAcceleratedOnline / Distance Only (the cost for practicum is not included in this program as noted on our website and your enrollment agreement, you will need to make sure you pay your practicum invoice in full before attending)Training Program Outside of Emerald Valley InstituteNot sure, I would like someone from Emerald Valley to verify which program I am enrolled in
If you selected "training program outside of Emerald Valley Institute" which training program are you currently enrolled in
If you are in a program outside of Emerald Valley Institute, please upload proof that you are in good standing in your current training program (this can be a screenshot of your student portal, a statement from your training program, or a transcript)

Cancelof
If selected 'Online / Distance Only' or 'Training program outside of Emerald Valley Institute' Program have you paid your Practicum tuition?

YesNoNot Sure, I would like someone at Emerald Valley Institute to contact me to verify or setup practicum tuition payment
If Selected 'Online / Distance' Only Program and are an Emerald Valley student: Please let us know which practicum session you are hoping to attend (please note Emerald Valley will attempt to place you in your chosen practicum session however practicum space is limited and space preference is given to students in the Standard and Accelerated programs)
Do you have transportation while you are in Eugene *Please note students who elect and qualify to do a psilocybin session must follow a transportation plan and must have transportation the day of their psilocybin experience

yesno
Name

First NameLast Name
Phone Number
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Participant
Interest in Participating in a Psilocybin Session During Practicum

As part of practicum, some students may have the opportunity to participate in a psilocybin administration session through Emerald Valley Holistic (EVH).
Participation is not required for graduation and is not guaranteed for any student.

Opportunities depend on:

OHA-regulated client eligibility and screening
Safety considerations
Practicum planning and capacity
Approval through EVH’s official intake, preparation, and consent process
Please Indicate Your Level of Interest for Psilocybin Services or Use of Alternatives:

Yes, I am interested in participating in a psilocybin administration session during practicum if I am eligible and approved.No, I do not wish to participate in a psilocybin session during practicum.I am undecided and would like more information.
Important Disclaimer — No Guarantee of Participation In the Use of Psilocybin Services during Practicum
Submitting this form does not guarantee that you will participate in a psilocybin administration session.
All psilocybin services must comply with:

OHA screening, eligibility, and safety criteria
EVH’s clinical judgment
Available practicum resources, scheduling, and capacity
Final determination of eligibility and participation is made only through the official EVH intake and screening process, not through Emerald Valley Institute.
If you are selected and eligible to participate in a Psilocybin Administration session during practicum you will need to bring $40 to cover the cost of the psilocybin analyte per OHA. By selecting this you are acknowledging that you understand students must cover the cost of the psilocybin analyte for their administration session.

Yes I understand & would still like to participate in a psilocybin session if I am eligibleNo, I do not want to participate in a psilocybin session during practicum
Consent to Observers During Psilocybin Services (Required by OHA Regulations)
If I choose to participate in a psilocybin administration session through Emerald Valley Holistic (EVH), I understand that psilocybin services provided during practicum take place in an Oregon Health Authority–licensed Psilocybin Service Center and occur within a supervised training environment. As such, I acknowledge and agree to the following:

My psilocybin services—including intake, preparation, screening, administration, and integration—may include the presence of other student facilitators, trainees, and EVH/EVI staff.
These individuals may be present as observers, shadows, trainees, support personnel, staff, and their participation is part of fulfilling practicum training requirements.
All students and staff are bound by confidentiality standards, professional conduct requirements, ethical expectations, and all applicable OHA regulations.
OHA requires explicit client consent before any observers or additional individuals may be present during psilocybin services.
If I elect to participate in a psilocybin session, I will be required to sign the official OHA-approved client intake and consent forms, which include consent for observers and other authorized individuals to be present during all phases of service.
(Students who do not wish to consent to observers must decline participation in psilocybin administration sessions.)

I understand and agree that if I participate in psilocybin services during practicum, I will be required—via OHA client intake and consent forms—to authorize the presence of student observers and staff during intake, preparation, screening, administration, and integration.I decline participation in Psilocybin Services during Practicum
Code of Conduct Agreement
Psilocybin Facilitator Training Program – Emerald Valley Institute

Welcome to the in-person immersive training program hosted by the Emerald Valley Institute. This Code of Conduct is in addition to all codes of coduct of Emerald Valley Institute and sets forth the expectations for all participants to ensure a respectful, confidential, and professional learning environment over the course of the multi-day training. By signing below, you agree to adhere to the following standards throughout your participation.

1. Respect and Safety

All participants are expected to foster an environment of mutual respect and psychological safety. Disruptive, aggressive, or disrespectful behavior toward facilitators, fellow trainees, or staff will not be tolerated. This includes any form of harassment, intimidation, or discrimination.

2. Confidentiality

Due to the sensitive nature of the content and personal sharing that may occur during training, all participants are required to keep strictly confidential any and all information heard, observed, or discussed during the program. This includes, but is not limited to, personal experiences, identities, medical or psychological information, and professional methods shared by peers or trainers.

Information shared in this training must not be disclosed, repeated, or discussed outside the training environment. Any breach of this confidentiality obligation will result in immediate removal from the program.

3. No Drugs, Violence, or Misconduct

Illegal drugs, alcohol, and unauthorized substances are strictly prohibited during practicum.
Participants may not attend practicum under the influence of any substance.

Students may have the opportunity to participate in a psilocybin administration session through Emerald Valley Holistic (EVH) as part of their practicum experience. Because practicum is conducted at an OHA-licensed Psilocybin Service Center, participation is only permitted under strict compliance with all OHA regulations and EVH procedures, including:

Completing the full client intake, preparation, and screening process
Meeting all OHA-required eligibility and safety standards
Participating in a supervised administration and integration session, if approved
Participation in psilocybin services is not guaranteed.
Eligibility is determined solely through EVH’s regulated screening process, safety considerations, and practicum planning.

Students who do not qualify for psilocybin services, or who choose not to participate, will engage in alternative, non-substance altered-states-of-consciousness training methods that fully meet practicum requirements.

Students are not required to use psilocybin in order to complete practicum or graduate from the program

Any form of violence, threats, harassment, or possession of weapons will result in immediate removal from practicum.

All participants are expected to conduct themselves professionally, ethically, and respectfully at all times.

All participants are expected to behave professionally, ethically, and respectfully at all times.

4. Consequences of Violating the Code of Conduct

Emerald Valley Institute reserves the right to immediately remove any participant who violates this Code of Conduct, with no refund of fees paid. Violations include, but are not limited to:

Breach of confidentiality
Use or possession of prohibited substances
Aggressive, violent, or abusive behavior
Harassment or discrimination
Any form of misconduct deemed unacceptable by the training staff

5. Fragrance-Free Environment

To maintain a safe and comfortable environment for all participants, this training is a fragrance-free space.

Participants must refrain from wearing perfumes, colognes, scented lotions, essential oils, or any other fragranced personal products during training hours. Many individuals have chemical sensitivities, asthma, or allergic reactions to scents, and even minimal exposure can cause health issues.

We ask all participants to be mindful and respectful of this requirement to ensure a healthy learning environment for everyone.
Make Sure you Bring the Following Items to Practicum:
1) Legal Form of Identification (You must bring this in order to enter the facility)

2) Laptop or Tablet (Fully charged, please bring a charger as well)

3) Notebook and or Journal and writing instrument

4) Personal: Blanket, Pillow, Yoga Mat, comfort items (optional)

5) Water Bottle, Snacks, Lunch items (optional)
Practicum Acknowledgment & Agreement
By submitting this practicum registration form, I acknowledge, understand, and agree to the following:

1. Practicum Requirements & Expectations
I understand that the practicum is a required component of the Emerald Valley Institute (EVI) Psilocybin Facilitator Training Program (unless I am enrolled in a distance-education track where practicum is optional).
I agree to participate professionally, ethically, and respectfully throughout the entire practicum.

2. Conduct, Safety, and Prohibited Behavior
Illegal drugs, alcohol, and unauthorized substances are prohibited at practicum.
I agree not to attend practicum under the influence of any substance.
Any violent behavior, threats, harassment, or possession of weapons will result in immediate removal from practicum.

3. Psilocybin Legal Status & Assumption of Risk
I acknowledge that psilocybin remains a Schedule I controlled substance under U.S. federal law and is federally illegal.
I understand that psilocybin services are permitted only under Oregon state law within licensed facilities and do not alter its federal status.
I acknowledge that participation in psilocybin services involves inherent and potentially unknown risks, including psychological, emotional, and physical risks.
By choosing to participate in any psilocybin session, I voluntarily assume all risks associated with psilocybin use.

4. Psilocybin Session Opportunities
I understand that some students may have the opportunity to participate in a psilocybin administration session through Emerald Valley Holistic (EVH), an OHA-licensed Psilocybin Service Center.
Participation is not required, not guaranteed, and not determined by this registration form.
Eligibility is determined exclusively through EVH’s OHA-regulated intake, preparation, screening, and consent process.

5. Alternative Training Methods
If I do not qualify for psilocybin services, or if I choose not to participate, I will complete non-substance altered-states-of-consciousness training, which fully meets practicum requirements.

6. Consent to Observers (Required for Psilocybin Participation)
If I choose to participate in psilocybin services, I understand and agree that:

Services may include the presence of other students and staff as observers, shadows, or trainees during intake, preparation, screening, administration, and integration.
All student and staff observers are bound by confidentiality, ethical standards, and OHA regulations.
OHA requires explicit client consent for the presence of observers.
I will be required to sign EVH’s official OHA-approved intake and consent forms, which include consent for observers.

7. Professionalism & Confidentiality
I agree to maintain strict confidentiality regarding all clients, including fellow students serving as clients.
I agree to uphold all EVI and EVH policies, professional standards, and OHA regulations throughout practicum.

8. Assumption of Responsibility
I confirm that I have read all practicum policies in full.
I understand that violating practicum policies may result in removal from practicum or other corrective actions.

By signing below, I confirm that I have read, understood, and agree to abide by the Code of Conduct outlined above and certify everything in this application to be true. I understand that violation of any part of this Code and or false information provided on this application may result in my immediate removal from the training program without refund.
Acknowledgment & Signature (Please Check Both Boxes to Proceed With Practicum):

I have read, understand, and agree to all practicum policies, requirements, risk disclosures, and statements listed above, including the federal status of psilocybin and the associated risks.I agree to comply with all EVI and EVH policies and all applicable OHA regulations throughout practicum.I certify that everything in this application to be true
Name

First NameLast Name
Signature
Signed This Date

MonthDayYear
Date
Should be Empty:

Student Practicum Registration

Practicum takes place at: Emerald Valley Holistic 1267 W 7th Ave Eugene OR

Make Sure you Bring the Following Items to Practicum: