It is imperative, you must be 100% truthful and accurate in completing this form in its entirety.  Your Responses to the following questions determine whether you may safely participate in a members-only sacred ceremony.  

The ceremony with Rise and Shine Ascension Sanctuary is primarily a spiritual undertaking and although personal growth can occur, the experience should not be seen nor is it designed to be a substitute for psychotherapy, psychiatric or other medical care. This ceremony is not appropriate for persons with certain medical conditions or for persons using certain medications. If you have any doubt or concerns about whether you should participate, consult with the organizer before attending. Please answer the following questions as completely and honestly as possible.

Please sign below if you understand the need to answer the following questions truthfully and accurately:

YOU MUST BE 100% TRUTHFUL AND ACCURATE IN COMPLETING THIS FORM

 

In addition to allowing us to evaluate your participation for safety purposes, this form also allows us to get a better understanding of what your intention(s) is in joining us for a scared ceremony.

We ask that you listen closely to what has drawn you to ceremony. Take some time to meditate and be with your heart’s intention. Please share those insights with us.

• Cardiovascular disease, including heart attacks
• Recent or current infections or communicable diseases
• Type 1 Diabetes
• Type 2 Diabetes
• High Blood Pressure
• Low Blood Pressure
• Mental Illness
• Recent Surgery
• Recent physical injuries (fractures or dislocations)
• Past physical injuries (fractures or dislocations)
• Glaucoma
• Retinal Detachment
• Epilepsy
• Asthma

CONTRAINDICATIONS: Please be aware that the list of contraindicated substances includes but is not limited to SSRIs, SNRIs, pain medication, cold and sinus medication, decongestants, nasal sprays, hay fever medications, diet pills, heart medication, amphetamines, MDMA, and other drugs and substances. If you have been using any drugs, medical, over the counter, or otherwise, please advise the organizer to discuss this matter further.

I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. My general health, as far as I am aware, is good.

IMPORTANT FOR WOMEN: If you are expecting to be on your moon time during the ceremony we ask that you wait to attend until the two do not coincide. Please feel free to ask for more information about this.

ATTESTATION

I hereby confirm that I understand the importance of answering the foregoing questions truthfully and to the best of my knowledge and ability.  This understanding is reflected in my initials at the top of this document. 

 

Therefore, I hereby represent that all answers to the foregoing screening questions are 100% truthful and accurate.  I further understand that my answers to the foregoing screening questions determine my eligibility to participate in Rise and Shine Ascension Sanctuary scared ceremonies; and if I am denied participation in a Rise and Shine Ascension Sanctuary sacred ceremony due to my answers to the foregoing screening questions, that such a denial is based on Rise and Shine Ascension Sanctuary’s determination that my exclusion is for the safety and benefit of myself and other ceremonial participants.

 

I understand that this screening form is attached to and made part of the Rise and Shine Ascension Sanctuary Waiver of Liability form.

I hereby warrant and represent that I am of sound mind and body, and it is my belief I am mentally and physically fit to participate in a Rise and Shine Ascension Sanctuary sacred ceremony, notwithstanding its staff's determination as to my fitness to participate.

I the undersigned hereby seek to participate in the ceremony with Rise and Shine Ascension Sanctuary. 

I understand the Sanctuary seeks to ensure the safety of all participants. In order to assist in this regard, I agree to complete the Confidential Medical History form provided. I am assured that the information provided will remain strictly confidential and will serve only as a guide in determining the appropriateness of my participation in the meditation and in meeting my needs before, during and after the ceremony. 

I have been informed of the nature of the medicine, the needed preparation, and the rules of the ceremony. I commit myself to stay in the circle until the end of the ceremony and to respect the directives given by the organizers, helpers, and leader(s) of the ceremony.