Sacred Ceremony Registration Form

Sacred Ceremony Registration Form

Thank you for your interest in joining this sacred ceremony. Please take your time to complete this questionnaire honestly and thoroughly. All responses will remain confidential and are used to create a safe and supportive space for everyone.The energy exchange for this ceremony is $222, with a $100 deposit required to reserve a spot. Deposits are refundable only if cancellation occurs at least 24 hours before the ceremony. The remaining balance is due on or before the day of the ceremony and is non-refundable once paid.
Participant Information
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Email *
example@example.com
Cell Number*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Phone Number*
Are you currently under the care of a medical provider? If yes, please specify the condition(s) or treatment(s) you are receiving care for.*
Are you taking any medications, supplements, or herbs?(Please list all.)*
Do you have any known physical or mental health conditions? (If yes, please elaborate.)*
Do you have any allergies (e.g., food, medication, environmental)?*
Have you worked with psilocybin or other plant/earth medicines before? If yes, please describe your experience.*
Have you experienced any adverse reactions to psilocybin, psychedelics, or other medicines in the past?*
Do you feel supported in your life outside the ceremony? If so, who or what is your primary source of support?*
Are there any specific areas of your life you’re seeking clarity, healing, or transformation in?
Are there any specific areas of your life you’re seeking clarity, healing, or transformation in?*
Do you have any comments, concerns, or anything else you would like to share with us regarding your participation in the ceremony?*
Are you pregnant, nursing, or could you be pregnant?*

YesNo
Do you acknowledge and agree to the cancellation and refund policy, which includes that the deposit is refundable only with at least 24 hour notice prior to the ceremony?*

YesNo
Are you able to commit to the guidelines and agreements set for the ceremony, including maintaining confidentiality and respecting the shared space?*

YesNo
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

This agreement is entered into between the participants and the facilitators of the sacred ceremony. The participant understands that this sacred ceremony involves the use of natural earth medicine and is not a recreational activity but a spiritual and personal growth experience. The participant agrees to take full responsibility for their physical, mental, and emotional well-being throughout the preparation, ceremony, and integration phases.

The participant acknowledges that the facilitators are not licensed medical or mental health professionals unless explicitly stated. This ceremony is not intended to diagnose, treat, or cure any medical or psychological conditions. The participant confirms they have disclosed all relevant health information, including any history of psychiatric conditions, cardiovascular issues, medications, or other factors that may impact their experience. The participant agrees to consult a licensed medical professional if they have any concerns about potential risks.

The participant understands that psilocybin can induce altered states of consciousness, which may involve challenging emotions, anxiety, or temporary disorientation. They voluntarily accept all risks associated with the ceremony, including but not limited to physical injury, psychological distress, or property damage. By participating, the participant releases the facilitators from any liability or claims arising from their participation and agrees to indemnify and hold them harmless from any resulting expenses or damages.

The participant agrees to follow all ceremonial guidelines, including respecting the sacred space, maintaining confidentiality about other participants, and refraining from disruptive behavior. The participant agrees not to share identifying information, personal experiences, or discussions about other participants outside the ceremonial space. Photography, video, and audio recordings are not permitted during the ceremony.

The participant understands that the facilitators reserve the right to end their involvement in the ceremony if it is deemed necessary for the safety and well-being of the participant or the group. In the event of an emergency, the participant consents to the facilitators contacting emergency medical services if required.

By signing this Agreement, the participant confirms they have read, understood, and agreed to all terms and conditions. The participant acknowledges they are participating voluntarily and take full responsibility for their own experience.
Signature*

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Date Signed*

MonthDayYear
Date
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