Ayahuasca Ceremony Registration Form

Guest Information

Name

First NameLast Name

Birthdate

Date

Email

example@example.com

Cell Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name

First NameLast Name

Phone Number

Alt. Phone Number

Emergency Contact's Name

First NameLast Name

Phone Number

Alt. Phone Number

Ayahuasca is not for pregnant women. If you have any doubts please take a test. Are you pregnant ?

Ayahuasca is not ideal for breast-feeding women, although women in South America so consume lesser amounts of Ayahuasca. Are you breast feeding ? ( we can help you with a protocol)

Have you taken Ayahuasca before ?

Did you suffer any adverse effects?

Are you taking medication for a heart condition, SSRIs or anti-psychotic medication

Are you taking medication for Parkinson disease or a dopamine agonist?

Taking ayahuasca with medications used for Parkinson disease might increase the effects and side effects of these medications.

Do you have any health issues that result in you fainting or having seizures.

If yes, to any of the answers above, please explain in a little more detail ?

Do you have a heart condition or have you been to the doctor with a suspected heart condition

If yes, to any of the answers above, please explain in a little more detail ?

Do you have any health limitations or physical injuries? Please indicate if you have any major health issues (ex high/low blood pressure, arthritis, asthma, diabetes, seizures, osteoporosis, etc.)

Do you understand that you can not take Ayahuasca if answer yes to any of the bullet points below? Antidepressants or any other drugs used to treat mental health conditions. Cough medicine St. John's wort Weight loss drugs Triptans Medications to treat Parkinson's disease Drugs such as cannabis, alcohol, cocaine, heroine & ketamine

Gender

MaleFemaleOther

Are you bothered by scents ( incense, burning sage or pala-santo etc.)? If yes, please let us know the details.

Do you have any special dietary requirements? (eg: gluten-free (please specify if you are celiac), allergies, vegan etc…)

What inspired you to come to this retreat?

Do you have any issues following the Candida cure diet before the retreat ?

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

I hereby agree to the following:

As I participate in activities offered by the hosts and special guests, I understand that the offerings of this retreat are not a substitute for medical attention, examination, diagnosis, or treatment.

I will receive fitness and cleansing-related information and instructions. I recognize that Ayahuasca is a plant medicine that causes visions and insights and during the journey, I am under the guidance of my sitter who guides and keeps me safe. It is my responsibility to do as they say while I am under the influence of medicine.

If at any time during the activities, I feel discomfort or pain, I will inform and seek assistance from the guides, volunteers and nurse on site.

I understand that it is my responsibility to consult with a physician before and regarding my participation in any activity program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my participation in the consumption of Ayahuasca.

I recognize that it is my responsibility to notify the retreat facilitators of any serious illness or injury before the retreat.

I accept that neither the facilitators or guide, nor the hosting facility, are liable for any injury, or damages, to person or property, resulting from my participation in this retreat.

I understand and agree to pay the stated costs of the retreat. I understand that there is a 50% cancellation fee on the £500 deposit paid if I cancel 4 weeks before the retreat. Further Cancellation fees will apply due to associated costs such as the catering service, accommodation, etc. I agree that all cancellations made less than three weeks in advance of the retreat be paid in full and that I may transfer my spot to another person.

Exclusion of Participation: In the unfortunate circumstance, if a guest conceals physical and/or health issues, is unfit, and/or causes disruptions that endanger the provision of the service and/or the health of other participants,facilitators, or equipment the guest can be excluded from the participation of the Retreat after an initial warning. If the situation arises, the contract will be terminated without further notice, already paid costs are non-refundable and incurring costs are to be paid by the guest.

I have read the above release and waiver of liability and fully understand it’s contents as well as the Refund/Cancellation Policies. I voluntarily agree to the terms and conditions stated above.

Signature

Date Signed

Date

Ayahuasca Retreat Registration Form