Equinox Ceremony Application

Please share your basic contact information with us to apply to attend our Ceremonies.

(Note: This is for internal use only)
Your Name*

First NameLast Name
Daughter's Name (if you wish to bring your daughter under the age of 19)

First NameLast Name
Your Email*
Example: KeylelaEffect@gmail.com
Your Mailing Address

Street Address

Street Address Line 2

City/Town/VillageProvince/Territory/State

Postal / Zip Code
Your Phone Number*
Please enter a valid phone number in case we need to connect with you.
🦋 Community Connections ~ Through our work with Elders, we have learned to ask people to share a short introduction that includes, "Where you are from, and who is your family?" We would appreciate learning about you! 🙏🏼
Let us know how you would like to stay connected!*

• You have my permission to sign me up for the monthly Keylela Effect Newsletter.• Please send me an email invitation to join your Wellness Webinars.• Please contact me to explore facilitating or speaking at future Wellness events.• Please send me info about Reciprocal Contributions (Sponsorship) Opportunities.• Please CALL me regarding this Wellness Ceremony.
What does Wellness mean to you?
What does Wellness mean to you?
Do you have any medical conditions or injuries that we should be aware of? If you have none, please type a short reply or "N/A"*
Do you have any known allergies or sensitivities (foods, insects, medications, plants, fabrics, etc.)? If you have none, please type a short reply or "N/A"*
Please list any dietary restrictions you may have. If you have none, please type a short reply or "N/A"*
Acknowledging Use of Images

Keylela Effect Moon Lodge Society will be gathering photos, videos and comments during our Wellness Ceremonies. If permission is granted, some insights and images of facilitators, our team and participants may be shared outside of the Ceremony or used by Keylela to expand the ripple effects of Wellness.
Please check the boxes below to acknowledge that you understand and agree to the terms of media gathering and use at Keylela events.*

Yes, I understand that I may be asked to be included in photos, videos, etc. but can decline any or all requests.Yes, I understand and will respect that recording or taking pictures during some of the Ceremonies or Cultural activities may not be allowed.Yes, I agree to respect the wishes of the Keylela Team, the Elders/Cultural Keepers/workshop facilitators and other event participants who may not want their images or comments recorded.
Keylela Effect Moon Lodge Society assumes no liability for lost, damaged or stolen items. Keylela Effect Moon Lodge Society assumes no liability for accidents or injuries that may occur while traveling to our events or participating in activities that we have planned. The Keylela team has First Aid Qualifications and extensive Cultural Safety awareness training, in the event those skills are needed. Please check the box below to acknowledge that you understand and agree to these terms.*

Yes, I understand that Keylela Effect Moon Lodge Society assumes no liability for any property or personal loss or damages related to participating in our events.

My Products

Keylela Effect ScholarshipAs part of our ongoing journey we acknowledge that Keylela Effect, as a place of reconnection to culture and ceremony, is not without its barriers. For many, being able to afford to attend Ceremony Weekends is a financial privilege. As part of our commitment to cultivate spaces of loving openness we aim to reduce some of the financial barriers by way of the Keylela Effect Scholarship Program. We ask that applicants meet the following criteria to apply for a scholarship: You identify as Indigenous, Aboriginal, First Nations, Metis or Inuit. We kindly ask if you are not experiencing financial need, that you consider paying for your experience. This helps us to prioritize individuals who do not have the financial resources to do so.

$ FreeCAD

This application is for:	Select #
Myself
A Woman I am nominating

Total

$0.00CAD

Your Signature - please sign or upload a digital copy of your signature.*

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Today's Date*

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Please type the date or select the date on the calendar above so that we know when registrations were submitted. Thank you
THANK YOU! Once you click the 'Submit' button below, you will receive a confirmation message.
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Please share your basic contact information with us to apply to attend our Ceremonies.

Acknowledging Use of Images

THANK YOU! Once you click the 'Submit' button below, you will receive a confirmation message.