FEAT Step 2: General Details

1

If you need help filling out this form please email or text this number +1619-366-7788 or use WhatsApp button below. Mention the word FEAT in your text.

2

What Brings You Here Today?* This field is required.SELECT ALL THAT APPLY

3

Your Name* This field is required.

First Name

Last Name

4

Your Phone Number* This field is required.SELECT COUNTRY CODE

5

Your Email Address* This field is required.

6

What is your intention as you go into this program? Please write a sentence or paragraph about it on the next screen. Intentionality is the number one biggest factor in your success. This is why it's called intention, in-tension. You are creating the goal and you are the one releasing the arrow.

7

My Intention Is Please introduce yourself briefly, then write a sentence or paragraph about your intention as you come into this program. Example: "My intention is to heal my addiction and create a new life."* This field is required.The text box will expand as you write.

8

Age, Height, Weight* This field is required.

9

Please check all that apply* This field is required.

I'm in active addiction

I'm a veteran

I'm a medical professional or integration provider

Other

10

Relationship Status* This field is required.Select all that apply

Single

In a relationship living separately

Married or in a domestic partnership

Married with Children

Divorced with Children

Is Anyone Who Lives With You In Addiction? Select if YES.

11

Your Date of Birth* This field is required.

Date

12

Preferred Way to Contact You?* This field is required.

Email

Phone Call

Text

13

Your Address* This field is required.

City

State / Province

Postal / Zip Code

Country

14

Price: The cost of treatment varies depending on whether you're here for addiction or psychospiritual, ibogaine or iboga, what substances you take, the severity of your condition and general health, as well as the treatment plan or clinic you choose and the options you select, like aftercare integration retreat or microdosing programs. Fees range from $4000 to $30,000+. Financial aid is not available for psycho-spiritual journeys, practitioner trainings, and iboga ceremonies. NOTE: Proof of Income will be required for those seeking financial aid.* This field is required.

100% Self-Pay

Partial FEAT Financial Aid

100% FEAT Financial Aid

15

If you were sent here from one of our qualified ibogaine or iboga retreat centers please indicate which one* This field is required.

Iboga Quest Center

Awakening in the Dream Ibogaine

Inner Realms Ibogaine Center

Soul Reflections Iboga

No, I was not sent from one of these clinics

I don't have any clinics in mind

I have a different clinic in mind

16

Please indicate the name (or names) of the clinic you have in mind* This field is required.If the clinic you name meets our quality and safety checklist we will invite them into the program

17

If You Selected Financial Aid Options Indicate How Much You Can Contribute. $2400 MINIMUM REQUIRED OF ALL CANDIDATES* This field is required.

18

Have you ever taken ibogaine or iboga before?* This field is required.

YESNO

19

Please upload a photo of yourself

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

Please upload a photo of yourself* This field is required.

21

Do you currently have a regular source of income?* This field is required.

YESNO

22

Please enter the monthly incomeProof of income will be required for financial aid applicants. Response optional for 100% self pay applicants.

23

If no, please briefly describe how you currently support yourself.Optional for self-pay applicants

24

Do you have a valid Passport and are you cleared to leave the country?* This field is required.If you have judgments, past due child support payments or other legal obstacles to overseas travel please indicate here.

YESNO

25

If you answered NO please briefly describe what the problem is* This field is required.

27

FEAT Financial Aid Applicant Agreements* This field is required.

a. I agree to raise $2400 of the total amount required to pay for my enrollment in the Nine Month Integration Program and kickoff the crowdfunding campaign.

b. I agree that it is my intention and responsibility to raise these funds by reaching out to my network. FEAT will assist me by helping create and promote the crowdfunding campaign through the Awake platform as well as trying to obtain discounts from ibogaine treatment providers, detox experts, integration providers and other healers and doctors. Discounts will be considered on a case-by-case basis.

c. I understand that my intention to heal is the most important ingredient, and I attest that I am NOT doing this to please someone else.

e. I understand that if I do not complete the preparation and detox milestones in a timely manner I will lose my spot and my $2400 deposit and will need to reapply for the FEAT program.

f. I intend to do my best to complete the FEAT Journey of Rebirth and be dedicated and diligent in my approach.

28

FEAT Self-Pay Applicant Agreements* This field is required.

a. I understand that my intention to heal is the most important ingredient, and I attest that I am NOT doing this to please someone else.

b. I understand that if I do not properly follow the detox and precare protocols I may not be able to do the ibogaine treatment and could lose my spot and my $2400 deposit.

c. I intend to do my best to complete the FEAT Journey of Rebirth and be dedicated and diligent in my approach.

29

Would you be willing to be documented on camera as a part of the FEAT grant, Iboga Saves documentary or Awake.net blog series? We are collecting stories about the journey of addiction recovery with ibogaine, both the inner and outer journey. We feel that it is important to de-stigmatize addiction and addicts in the eyes of the general public. Through our first person mini-documentaries people can learn the details and best practices of how to prepare for ibogaine by watching someone else go through the process of preparation, travel, ibogaine treatment, and finally integration. All four steps are super-important. Our culture has been conditioned for many years to fear psychedelics, but new research is emerging everyday about the powerful and vital role that psychedelic medicines play in our physical, psychological and spiritual health, and major academic institutions are opening departments to research these mind-manifesting molecules. However because all research and medical use has been suppressed in most Western cultures since the 70's, there is still very little medical data or research available about ibogaine. Unlike other psychedelics, ibogaine can lead to cardiac arrest if taken under certain health conditions or in the presence of other contraindications, both known and unknown. In the absence of medical research, these anecdotal narratives will play a vital role in educating the mainstream. NOTE: THIS IS NOT A REQUIREMENT AND YOUR ANSWER WILL NOT AFFECT YOUR CHANCES OF BEING ACCEPTED INTO THE PROGRAM OR GETTING FEAT FINANCIAL AID.

30

Media Consent for Iboga Saves documentary or Awake.net blog series * This field is required.

YES

NO

I'M NOT SURE

31

Media Consent & Release Form I, for myself and on behalf of my heirs, successors, and assigns, hereby irrevocably and perpetually grant to Lakshmi Narayan and Awake Media (the “Producers”) his/her heirs, executors, licensees, successors and assigns:* This field is required.

I the undermentioned FEAT applicant accept and agree to be documented and grant you rights to use my footage as named above.

32

Waiver of Liability and Informed Consent* This field is required.SCROLL TO BOTTOM AND CHECK BOX IN CONSIDERATION OF the risk of injury that exists while participating in IBOGAINE TREATMENTS FOR ADDICTION THROUGH AWAKE.NET'S FEAT PROGRAM (hereinafter the "Activity"); and IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same; I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and I HEREBY release and forever discharge AWAKE.NET'S FEAT PROGRAM, located at 1228 University Ave, San Diego, California 92103, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity. I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY. I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs. I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize awake.net's FEAT program to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the awake.net's FEAT program official or agent, regarding my approval to participate in the Activity. I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE awake.net's FEAT program AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST awake.net's FEAT program FOR PERSONAL INJURY OR PROPERTY DAMAGE. To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of awake.net's FEAT program, its agents, and Employees. I agree that this Release shall be governed for all purposes by California law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements. In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness. THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION. THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both FEAT applicant, and awake.net's FEAT program agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. In the event of an emergency, please contact the following person(s) in the order presented: Emergency Contact Contact Relationship Contact Telephone I, THE UNDERSIGNED FEAT APPLICANT, AFFIRM THAT I AM 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

I, the undermentioned FEAT Applicant agree to the waiver of liability

33

Waiver of Liability, Informed Consent & Agreements Signature* This field is required.

Clear

34

Name* This field is required.Name of Signee

First Name

Last Name

35

Hit Submit to Proceed to Step 3, Life History