Harmony PEC

Full Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date

Birth Time

Birth Location

I agree to answer the following questions truthfully and accurately for my safety.

Ceremony Date

Referred By:

Emergency Contact Name

Emergency Phone Number

Please select one of the following:

If couples or custom, please provide the names and contact information of all participants.

Have you worked with sacred plant medicine previously?

If yes, how many times? (or N/A)

If yes, what type of sacred medicines have you sat with?

If yes, have you ever been hospitalized because of it?

Have you ever received a mental health diagnosis?

Please specify diagnosis if given one

Is there a history of mental health diagnosis in your family?

Please specify diagnosis if given any for family members?

Are you taking tramadol or lithium?

Are you taking any SSRIs, anti-depressants, anti-anxiety or any other medication?

If yes, list any medications you are taking.

Are you pregnant

Please list any food allergies or sensitivities.

I agree NOT to operate a motor vehicle for 12 hours after the ceremony.

I understand that the facilitators will be guiding and acting as journey sitters during the ceremony as I am under the influence of sacred plant medicine(s). I will be consuming the sacred plant medicine by my own personal choice.

I waive the right to initiate any claims or litigations against Harmony PEC Retreat Centre and all practitioners for their advices, recommendations, assessments and outcomes of their services.

I agree that if I am sick or feel the onset of sickness or extreme fatigue the day of ceremony, that I will contact Harmony to cancel or reschedule.

By submitting this application form, I agree that I have answered all the above information accurately and truthfully.

Would you like be a part of Harmony's mailing list for future events?

I acknowledge that participation in the sacred ceremony may involve discomfort
and unexpected physical, mental or emotional upset.
In signing this release document, I agree to waive all rights to seek or receive compensation in case of injury, loss or damage.
Participation in the sacred ceremony includes the ingestion of an entheogen.
I am informed of the objectives of experiencing this sacred medicine and of its
possible effects.
I choose to attend this session as a result of my research and interest in this event.
I understand that my participation in this ceremony is entirely voluntary and I agree to remain at the ceremony to its completion.
I accept that the ceremony leaders and helpers make no claim or promise about the curing of illness of any kind, or about the nature of any spiritual experience which I understand is entirely personal.
I understand that my participation in the session may be physically, mentally,
emotionally or spiritually demanding.
I understand that I may experience dizziness, vomiting or other physical manifestations.
I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional and mental changes.
I acknowledge that I am aware of the risks and potential benefits of my participation and I freely choose to enter this process, accepting full responsibility for whatever may occur whether anticipated or unanticipated.
I understand that the use of any drugs or prescribed medication may interfere or have an adverse effect if ingested prior to, during or after the use of the sacred medicine.
I acknowledge that the proper dietary guidelines have been provided to me and I take full responsibility for adhering to those guidelines
I acknowledge that, I will make alternate arrangements for transportation in the
event that I may be physically or mentally exhausted and/or disoriented after the ceremony.
I am informed of the nature of the ceremony, the needed preparation and the
rules of the ceremonies.
I commit myself to stay in the ceremonial premises until the end of the ceremony and to respect the directives given by the organizers, helpers and facilitators of the ceremony.
I hereby attest that I am not ingesting any drugs or medication at this time that have not been listed on this waiver.
I hereby knowingly and voluntarily assume the full risks of any physical or
moral injury, damage or losses, either to myself or caused to others by me
during the Ceremony.
I hereby waive the liability of and agree to hold harmless Harmony P.E.C., and all of the helpers, associates, employees, agents, staff, family successors, volunteers and other participants. I further agree to defend and indemnify them from any claims, suits and demands.
This agreement is binding upon myself, my spouse, parents, family, heirs,
executors, administrators, agents and assigns.

This waiver / medical form is valid for all ceremonies. It is your responsibility to update Harmony of any changes prior to attending a ceremony, retreat, event or workshop.

I HAVE READ, UNDERSTAND AND TAKEN TIME TO CONSIDER THIS WAIVER. I SIGN THIS AGREEMENT VOLUNTARILY

This waiver is valid for all ceremonies I participate in, unless I provide written cancellation forwarded to Harmony PEC Ltd.

Date

Signature