The Mastermind Education Extension Program
Program Interest and Application Form
Name
*
First Name
Last Name
Best Email for Program Communications and Updates
*
example@example.com
Have you previously completed and been awarded your certificate for the Psychedelic Screener Mastermind Program?
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Yes
No
I completed the program and still need to finish up a requirement or two for my certificate. I can finish this prior to this program starting if I'm accepted
Do you have an idea for an educational project or specialty that you would like to focus on during the program?
*
I understand that part of this program is coordination of personal meetings with an assigned partner and/or Dr. Malcolm. Dr. Malcolm strongly prefers and will provide availability for these meetings to be conducted during daytime business hours, although could be conducted at other times found mutually agreeable. Do you think you can find times to meet with my partner or Dr. Malcolm and to prepare for, attend, and participate in these meetings?
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Yes, I think I can do that
No, I doubt I can do that
Possibly, I really don't know
I understand that the Mastermind Education Extension Program is aimed at development of a case-based or standard of care type educational project. I further understand and agree to it that presentation of my project within a cohort of the Psychedelic Screener Mastermind is a required part of the program and that I'm granting a 1 time royalty free use license to Spirit Pharmacist LLC for this presentation. The presentation will be recorded and used exclusively for the current cohort of the Psychedelic Screener Mastermind. Beyond this presentation I understand the project created is my own intellectual property and that further use by Spirit Pharmacist LLC will require us to engage with a licensing or revenue share arrangements. I understand and agree to it that these arrangements are discretionary to both parties and contingent upon successful completion of the program.
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Yes, I understand the arrangement and agree to this
No, I don't think I understand the arrangement well enough to agree
No, I understand the arrangement but do not agree
I agree that if I was admitted to the program that I would act respectfully towards other participants, hold their names and any other information they may share in confidence, and generally do not mind sharing my own name, professional background, and experiences within the closed container of the program.
*
Yes, I could agree to all that
No, I'm not able to agree to this
Is there anything else you would like to communicate about your application to participate in the Mastermind Education Extension Program or questions about the program you currently have?
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