Caya Sanctuary Intake Questionnaire

Spiritual Diet Information and Guidelines
Nutritional and energetic guidelines for sacred diet:

It is extremely important to commit to preparing physically and energetically for the ceremony. It is necessary to ensure your safety and for you to receive the best results from the experience. It not only helps your body to receive the healing of Ayahuasca, but it also reduces any unnecessary purging due to excess toxins in your system. Additionally, it is a commitment, respect and devotion to the sacred medicine you are preparing to receive and to yourself. If you feel that you may need additional support concerning the diet please let us know, we are here to help.

Four to Six weeks prior to ceremony:
- Stop the use of any street drugs.
- Stop the use of Cannabis.
Two weeks prior to ceremony (and post ceremony):
- Be mindful of the media you ingest, including anything that is meant to induce strong emotions or portrails of traumatic events (violence, stress, sadness, etc.). These energies can influence the ceremony experience.
- No Alcohol
- No Red or heavy meats (pork, beef, sheep, eel, etc.)
One week prior to ceremony (post ceremony) none of the following:
- Sexual activity or exchanges with other, including masturbation (this allows your energy to be strong, clear and purely yours).
- Dairy products
- Refined sugars
- Smoked products
- Junk food
- Citrus
- Minimize salt intake.
- Oils (only use olive, avocado or coconut oil sparingly)
- Animal fats
- Carbonation (soda, seltzers, energy drinks)
- Fermented food or drinks (Kombucha, non-alcoholic beer, kimchi, sauerkraut, kefir, pickles, yogurt)
- Aspartame
- Chocolate or peanuts in large amounts
- Dietary supplements and protein powder/bars
3 days prior to ceremony (post ceremony):
- Eat healthful meals with low levels of salt, sugar, and fat.
- No Caffeine and other stimulants (Decaf and Green Tea is okay, in small amounts)
- No spicy foods
- No Fried foods
Day of Ceremony (and day after):
- Please eat, fasting is not recommended. Eat clean, healthy foods.
- Simple breakfast and lunch.
- No food after 1pm
- Drink only water, coconut water or herbal tea after lunch.
Post Ceremony:

Continuing to adhere to the diet will allow the medicine to continue working, healing and aligning your system to its fullest capacity.
Please list any food allergies or sensitivities.
Please list any food preferences or dietary restrictions.
I have read and understood the sacred diet guidelines (dieta) and will adhere to them in preparation for the ceremony.*

I understand and agree
Signature*

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Participation Waiver and Release of Liability
CAYA Sanctuary

Participation Waiver

For all participants involved in CAYA Sanctuary of Washington activities including but are not limited to CAYA Sanctuary retreats, ceremonies, breathwork, yoga, hiking, activities in or near flowing water and (others) on the property located at 686 Winston Creek Rd, Mossyrock, WA 98564.

Coronavirus/COVID-19 Acknowledgement & Commitment

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and other public health authorities still recommend practicing social distancing.
I further acknowledge that the CAYA Sanctuary may invite me to be within 6 feet of other practitioners or participants.
I further acknowledge that the CAYA Sanctuary cannot guarantee that I will not become infected with the Coronavirus/COVID-19.
I voluntarily seek these sessions provided by the CAYA Sanctuary and acknowledge that I may be increasing my risk of exposure to the Coronavirus/COVID-19.
As an adult over the age of 18 years old I take personal responsibility for my health and my participation in the CAYA Sanctuary.

I attest that:

I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
I have not traveled internationally within the last 14 days.
I have not traveled to a highly impacted area within the United States of America in the last 14 days.
I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
I have not been diagnosed with Coronavirus/COVID-19 and not yet cleared as non-contagious by state or local public health authorities.
If after a session I learn that I have been exposed or diagnosed with Coronavirus/COVID-19 I will contact Crystal Espiritu or Damian Espiritu.

CAYA Sanctuary Programs

I understand that ceremonies may include physical movement, breath, meditation, release of emotions, touch, bodywork, massage, crafting, hiking, outdoor activities, fire and sound. I understand that these modalities give an opportunity for release of chronic muscular tension and free flow of energy in the body.
As is the case with any physical activity, the risk of injury, even serious disabling, is always present and cannot be entirely eliminated. If I experience pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from a facilitator. I assume full responsibility for any and all damages, which may incur through participation.
I understand that the facilitator does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals.
I understand that Breathwork (and other modalities mentioned above) are not substitutes for medical care and that it is recommended that I work with my primary care physician for any condition I may have.
I confirm that I am not pregnant, nor have severe asthma, severe heart disease, a mental illness, epilepsy/history of seizures, acute physical injuries or severe diabetes.
Breathwork and other activites are not recommended under certain medical conditions. These are contraindications, to which I have been made aware. I will make the facilitator aware of any medical conditions or physical limitations before the session.
I am not intoxicated by alcohol or drugs.

Release of Liability

I also affirm that I alone am responsible for deciding whether to participate in any CAYA Sanctuary related activities and that participation is at my own risk. I acknowledge and affirm that my participation in any on-property activities such as, but not limited to, the use of the sauna, hammocks, hot tub, lodging accomodations, river/creek and hiking is solely voluntary and I accept full responsibility for any associated risks involved and release any liability to CAYA Sanctuary for personal or physical injuries resulting from my voluntary participation in these activities.

I hereby release and agree to hold CAYA Sanctuary and the property owners of 686 Winston Creek Rd, Mossyrock WA 98564 harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the institute, or that may otherwise arise in any way in connection with this training received from CAYA Sanctuary. I understand that this release discharges CAYA Sanctuary from any liability or claim that I, my heirs, or any personal representatives may have against the institute with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any training received from CAYA Sanctuary. This liability waiver and release extends to the institute together with all entities, properties, owners, partners, facilitators and employees associated with CAYA Sanctuary.

I understand that this Waiver and Release agreement is binding on me, my spouse, my heirs, my executors, administrators, personal representatives and assigns.
I am aware of the dangers of attending these events on these particular dates. I promise not to hold the company, its officers, agents, or employees liable or pursue legal action against them. This waiver absolves the company of any duty for injuries sustained on the premises before, during, or after the activity. By signing this agreement, I agree to hold the company completely harmless, including financial responsibility for any injuries sustained, regardless of the cause or circumstances. I will do all in my power to obey corporate staff and all safety requirements, and I will seek clarification if necessary.
Waiver and Release

I, {participantName}, am an adult of sound mind and body and am more than 18 years of age. I am aware that I have elected to participate in a retreat held by CAYA Sanctuary. During the retreat, I may be drinking tea containing plants from the Amazon basin in Peru, and may be offered tobacco or other herbal medicines. I have been warned that this tea may have health and medical side effects and contraindications when taken with other medicines or supplements, and I have been told what these side effects and contraindications are. I am not taking any medicines or supplements that might interact with the tea. I have been instructed how to diet prior to this experience, and I have followed those instructions. Additionally, I know that after drinking this tea I may experience vomiting, diarrhea, stomachache, body temperature changes, crying, sweating, blood pressure changes, visionary experiences, or other side effects of which I have been warned.

I certify that the medical information I have given to the organizers is complete and accurate, and that I am healthy and safe to ingest the tea. I acknowledge that I do not have any physical limitations, medical ailments, physical or mental disabilities that would limit or prevent me from participating in the above-mentioned activity, and, if required, will obtain a medical examination and clearance. If I have any such physical or mental disabilities that I am aware of, I will inform the retreat’s organizers or leaders in writing before participating in such activities.

In addition, I agree not to hold CAYA Sanctuary, its owners, officers, employees, affiliates, members, agents, organizers, leaders, assistants, participants, legal representatives, the owners or representatives of the property we are on, or anyone else responsible for my choice to participate in the retreat, my decision to drink the tea, and any physical, mental, emotional, or spiritual effects that may occur before, during, or after the retreat, including illness, sickness, or any side effects. I waive, release, and discharge CAYA Sanctuary (and others noted above) from all liability for or by reason of any damage, loss, or injury to person and property, even injury resulting in my death. I take full responsibility for my actions. I take full responsibility for my body, health, and well-being.

I hereby acknowledge and agree that by signing this release I have read the information sheet and acknowledge the risks and responsibilities of my participation in the above stated activities to others and myself. I also acknowledge that by signing this release, I will be forever prevented from suing or otherwise claiming against CAYA Sanctuary (and others noted above) for any property loss or personal injury that I may sustain while participating in or preparing for the above noted activity. I have been given the opportunity and have been encouraged to seek independent legal advice prior to signing this Waiver and Release agreement.

I understand that this Waiver and Release agreement is binding on me, my spouse, my heirs, my executors, administrators, personal representatives and assigns.
Signature*

Clear
Date

MonthDayYear
Date

CAYA Sanctuary Intake Form

Welcome to CAYA Sanctuary

Participation Waiver and Release of Liability

CAYA Sanctuary Church Membership