Booked and Bougie MD/PhD Circle Application

Booked and Bougie MD/PhD Circle Membership Form

Complete the form below to request your membership. You must complete all the fields to be considered. Please take your time and answer the questions thoroughly; one word or short answers will not be accepted.
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Are you a Black woman?
How did you hear about us?

Other
What is your current role or title?
Which best describes your profession?
If you chose other, please specify your profession below
Please list any degrees or certifications you hold (e.g., MD, PhD, LCSW, PsyD, NP, etc.):
Are you currently practicing or working in your field?
What does luxury mean to you beyond material things, and how do you embody that in your daily life?
This community was created for the 92% of Black women who supported Kamala Harris. Does this reflect your political values and the kind of sisterhood you’re seeking?
Why are you interested in joining The MD/PhD Circle?
What are you currently seeking more of in your life or professional journey? (Check all that apply)
How do you currently care for your mental and emotional well-being?
What are your thoughts about gossip, and how do you normally handle conflict? Please provide a detailed example of how you managed conflict with another woman in recent memory. What was the result?
What do you hope to give to this space?
This space is designed to be free of performance, ego, and toxicity. Are you open to participating with vulnerability, softness, and mutual care?
Is there anything else you’d like us to know as we review your application?
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Booked and Bougie MD/PhD Circle Membership Form

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