Diversify Psychedelics
After vetting, your information will be recorded in a public directory moderated by the Intercollegiate Psychedelics Network (IPN). IPN aims to identify rising leaders from traditionally underrepresented or underserved groups in the psychedelic space (e.g., racial or ethnic minorities, people with disabilities, women, people who identify as LGBTQIA). Our goal is to help organizations, symposium organizers, award committees, search committees, etc. identify psychedelic scientists who can contribute important, unique, and diverse perspectives in the field.
Sign in to Google to save your progress. Learn more
Name *
Affiliation *
Country *
Have you submitted this form before? *
Required
Field *
Required
Sub-field Keywords *
Additional information on your sub-field such as what psychedelic compound or illness you focus on. Please limit to 5-7 words.
Current Career State *
Email Address *
Website *
Personal professional website, lab website, LinkedIn page, google scholar profile, or other professional information. This is useful to identify your work and contributions in the field.
Twitter Handle
Gender
Clear selection
Race/Ethnicity/Self-Identification
Additional race/ethnicity information
Optional: If you would like to add additional self-identification information beyond the categories you selected above, please write in your information here (e.g. country of origin, citizen in a tribal nation)
Additional Self-Identification Information
Please remember that this is a public disclosure and you should not disclose anything you are uncomfortable with being public knowledge. Some of these identities may not have discrimination protections in all places.
Additional Identity Information
Optional: If you would like to add additional self-identification information beyond the categories you selected above, please write in your information here (e.g., first-generation PhD student, economic hardship, attended rural high school, Muslim, sex worker, and so on - please use only short descriptors).
Dis/Ability Identification
Please remember that this is a public disclosure and you should not disclose anything you are uncomfortable with being public knowledge.
Additional Dis/Ability Information
Optional: If you would like to add additional self-identification information beyond the categories you selected above, please write in your information here.
Thank you!
We screen submissions so your name will not be immediately placed on the public spreadsheet. If you do not see your name on the list by the end of the quarter (Dec, March, June, Sept), please resubmit or email us at media@intercollegiatepsychedelics.net
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report