Bufo Healing Sanctuary Intake Waiver

Comprehensive Waiver of Liability & Sacred Consent Bufo Healing Sanctuary Non-Profit Entheogenic Sanctuary

Transformational Spiritual Healing Sanctuary LLC
Step #1.

Please read the waiver and sign below that you have fully read and acknowledged. Before your ceremony, you will be able to sign the waiver as well. I recommend reading through all the medications that may contradict Bufo Alvarius or any other Entheogenic listed on the waiver. We will discuss this during your discovery call if it pertains to you. Thank you!
Name of Participant*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email of Participant*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Phone Contact/Relative*
Please enter a valid phone number.Format: (000) 000-0000.
What is your relation to this contact?*
Which Sacred Medicine Practitioner are you work with?

Marla B. Lindner(Texas)/Elder & Owner/Bufo, Huachuma & Iboga TALogan Lund(Utah)/BufoLaura Whittome(Malta)/Bufo, Huachuma & Iboga TA
Definition of Activity: The Activity refers to all retreats, ceremonies, microdosing programs, workshops, energy work, preparation sessions, integration sessions, facilitator training and spiritual or entheogenic services and training provided by Bufo Healing Sanctuary and/or Marla B. Lindner and facilitators.*

I understandI do not understand
Assumption of Risk: I acknowledge that I am voluntarily participating in this Activity, which involves inherent risks including but not limited to physical injury, psychological trauma, emotional release, or death. These outcomes may result from my own or others' actions. I fully accept all associated risks.*

Yes I agreeNo I do not agree
Medical Disclosure & Screening: I confirm that I have disclosed all relevant medical history and medications, including any psychiatric diagnoses. I affirm I am not diagnosed with or have a family history of schizophrenia, bipolar disorder, or psychotic disorders unless otherwise disclosed. I understand that these services are not a replacement for medical or psychiatric care.*

Yes I agreeNo I do not agree
Informed Consent & Contraindications: I have received information about contraindicated medications and health risks associated with entheogenic sacraments including Bufo Alvarius, Kambo, Psilocybin, Huachuma (San Pedro), Iboga, Rapé, Sananga, Banisteriopsis Caapi vine, Cacao, and Changa. I am not taking prohibited substances.*

Yes I agreeNo I do not agreeI am currently on medications and would like to discuss options
Spiritual Disclaimer: I understand that facilitators are not medical professionals and act only in the capacity of spiritual guides. All services provided are for spiritual and educational purposes only and not intended to diagnose or treat any condition.*

Yes I agreeNo I do not agree
Conduct & Confidentiality: I agree to follow all facilitator instructions, to stay within designated ceremony areas, I will surrender my keys and devices if required, and will protect the confidentiality of other participants. I agree to conduct myself as a guest and not have uninvited touch.*

Yes I agreeNo I do not agree
Photo & Media Release: Unless I specifically opt out in writing, I give permission for Bufo Healing Sanctuary to use photos or video of me during events for education or promotion. I understand no financial compensation will be given.*

Yes I agreeNo I do not agree
Emergency Care: I authorize Bufo Healing Sanctuary to provide emergency care including CPR, first aid, AED use, or medical transport if necessary. I assume financial responsibility for such care and understand I should carry my own insurance.*

Yes I agreeNo I do not agree
Damage Liability: I agree to be financially responsible for any damage to property or equipment caused by my actions or negligence during the Activity including ceremony and retreats.*

Yes I agreeNo I do not agree
Dispute Resolution: I agree that any disputes arising from this agreement shall first be attempted to be resolved through mediation. If unresolved, arbitration will be used. This waiver is governed by the laws of the State of Texas.*

Yes I agreeNo I do not agree
No Refund Policy: I understand that any payments or donations made for participation in ceremonies or retreats are non-refundable.*

Yes I agreeNo I do not agree
Acknowledgement & Full Agreement: This agreement is entered into without duress and reflects the full understanding between both parties. It shall remain in effect for all future participation unless revoked in writing.*

Yes I agreeNo I do not agree
List of Contraindication Prescriptions & Substances SSRIs: Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Fluvoxamine (Luvox) SPARI: Viibryd (Vilazodone), Trintellix (Vortioxetine) SNRI: Venlafaxine (Effexor), Duloxetine (Cymbalta), Levomilnacipran (Fetzima) DNRI: Bupropion (Wellbutrin), Mirtazapine (Remeron) Tricyclic Antidepressants (TCA): Amitriptyline (Elavil), Nortriptyline (Pamelor), Clomipramine (Anafranil), Imipramine (Tofranil), Desipramine (Norpramin), Chlorpheniramine, Trazodone (Desyrel) MAO-A Inhibitors: Phenelzine (Nardil), Isocarboxazid (Marplan), Tranylcypromine (Parnate), Moclobemide MAO-B Inhibitors: Selegiline (Emsam) Herbals: St. John's Wort*

I am not on any of these substances and agree to share with Practitioners if I take any medications that could be a contraindication.No, I do not agree to this.I am on a contraindication and would like to learn more
IF Choosing "OTHER", Please explain
I agree to not bring any drugs and/or alcohol to the property.

YesNo
I represent that I am not currently taking any of the medications listed that are contraindicated with natural entheogenic substances, such as those to be consumed as part of the Activity, as defined herein.*
Step #2 Release of Liability and Assumption of Risk

In consideration of being allowed to participate as a guests or student in all Entheogentic Ceremonies and all Retreats, including Bufo Alvarius, Kambo, Psilocybin, Huachuma (San Pedro), Iboga, Rapé, Sananga, Banisteriopsis Caapi vine, Cacao, and Changa. (“Sacred Ceremony”) I execute this Release of Liability and Assumption of Risk (“Release”) binding my heirs, executors, administrators, personal representatives, next of kin, and assigns, and do hereby release, waive, discharge and will not hold liable Bufo Healing Sanctuary, or any representative of the Church administering or assisting in the Sacred Ceremony (each, a “Facilitator”) for any actions, causes of action, expressly including negligence, claims, demands, costs, or damages arising from or resulting from property damage, personal injuries or death sustained by me or my property while participating in the Sacred Ceremony, regardless of the sole, joint, or concurrent negligence, negligence per se, gross negligence, strict liability, regulatory or statutory liability, tort theory, act, omission, fault or failure to act by the Church or any Facilitator while I am participating in the Sacred Ceremony in any capacity.

I further agree, binding my heirs, executors, administrators, personal representatives, next of kin, and assigns, to indemnify, hold, and save harmless the Church and each Facilitator from liability, action, claim damage, award, or judgment incurred or suffered by any third party as a result of any act or omission by me or caused in whole or in part by me while participating in the Sacred Ceremony whether or not also caused in part by a person indemnified hereunder.

In addition, I make the following representations and acknowledgments upon which I intend the Church and each Facilitator to rely:

1. I have read the above List of Prohibited Prescription Medications and I am not currently under the influence of or am prescribed or have ingested any of the medications and/or substances listed therein within the past 4 weeks that could potentially lead to an adverse reaction with all Entheogens, including Bufo Alvarius, Kambo, Psilocybin, Huachuma (San Pedro), Iboga, Rapé, Sananga, Banisteriopsis Caapi vine, Cacao, and Changa. (“Sacred Ceremony”)

2. I am participating in the Sacred Ceremony solely for the purposes of furthering a sincere religious belief and consider my participation to be a sincere religious exercise.

3. Neither the Church or any Facilitator had made any representation or warranty that the Sacred Ceremony is without risk.

4. I have carefully read this Release and sign this Release of my own free will and accord, without reliance of any representation of any kind or character by the Church or any Facilitator which is not expressly set forth in this Release. I am legally competent to execute this Release and I understand that I have the right to consult with a lawyer prior to signing this Release.

This Release is intended to be as broad and inclusive as permitted by the laws of the State of Texas and all US States. If any portion of this Release is held to be invalid, unenforceable, or illegal in any respect, such provision shall be fully servable, and the remainder of the Release shall remain valid and in full force and effect.

This Release contains the entire agreement regarding the release of liability and assumption of risk. This release shall be governed by the State of Texas and all US States.
Signature of Participant: I agree to all of the above questions and with my signature below, I am bound to this agreement between myself "Participant" and the Host "Bufo Healing Sanctuary LLC"*
Todays Date*

MonthDayYear
Date
Step #3 Medical Questionnaire

PLEASE BE 100% TRUTHFUL AND ACCURATE IN COMPLETING THIS FORM AS YOUR RESPONSES TO THE FOLLOWING QUESTIONS DETERMINE WHETHER YOU MAY SAFELY PARTICIPATE IN A CEREMONY FACILITATED BY BUFO HEALING SANCTUARY .YOU MAY BECOME A MEMBER OF BUFO HEALING SANCTUARY EVEN IF YOU ARE NOT ABLE TO PARTICPATE IN THE CEREMONY. PLEASE SIGN BELOW KNOWING YOU HAVE ANSWERED ALL THE QUESTIONS HONESTLY. Thank you for allowing us to evaluate your participation for safety purposes. We want to get a better understanding of who you are, what your intentions are, and how we can give you the best integration services possible.
We would like to get to know YOU! What brought you to Bufo Alvarius and to Bufo Healing Sanctuary?*
Do you have any past or current physical or mental health condition? (If yes, please explain)*
Have you ever been diagnosed with a mental health disorder (e.g., depression, bipolar disorder, schizophrenia/schizoaffective disorder/ paranoia/psychosis, eating disorders, obsessive compulsive disorder, suicidal thoughts/actions, self-harm thoughts or actions, impulsivities, history of violence, anxiety/panic attacks, ADHD/PTSD, any personality disorder, etc.)?*
In the past twelve (12) months have you taken or are you currently taking any type of medications, vitamins, or supplements?*
Are you currently detoxing from heavy metals and parasites? If not, would you like to learn about detoxing?*

YesNo
Have you ever consumed natural entheogenic/psychoactive medicines before. If yes, what were they and what were the effects? *
Are you currently under the care of a family physician, mental health professional or any other health professional?*

YESNO
Are you a highly sensitive person? If so, please explain.*

YESNO
Please expain here.
Have you been diagnosed by a medical professional with any of the following?*

Heart ConditionDiabetes 1 or 2CancerIBS/Ulcerative Colitis/Crohn's DiseaseAsthma/COPD/Breathing Issues/EmphysemaEpilepsy/SeizuresBleeding DisorderKidney DiseaseThyroid DiseaseLiver DiseaseCardiovascular DiseaseArthritisBronchitisHepatitis A B or CHigh/Low Blood PressureTraumatic Brain/Head InjuryNone
Do you have any allergies? (e.g.: foods like Nuts or Dairy, medications like penicillin, pollens/molds/Hay/Cedar, chemicals like fake sugars or dyes, animal hair/dander, etc.) *
Which of these substances have used in the past?*

HallucinogensAmphetiminesMethamphetiminesNicotine ProductsAlcoholCocaine/CrackInhalantsPCPSedatives/Sleeping PillsOpiate pillsMarijuanaHeavy use of CaffieneHeroin/FentanylSuboxone/MethadoneXanax/Valium/AtivanMedication Abuse of NON prescribed MedicationKratom/K2/Ecstasy/MollyOtherNone
Have you been diagnosed with TBI and if so, please share details

YesNo
Share Here:
Anything to add about addiction or drug history?
What age did you start first use and age at last use of any of the substances above. (Example: Alcohol - 13, 35)
What substances are you currently taking in the above option? Hallucinogens, Cocaine, Crack, Inhalants, Marijuana etc......
Have you ever had a spiritually transformative experience (STE) such as an out of body experience, near death experience (NDE), kundalini awakening, any Clairs, mystical or spiritual experiences (not induced by a psychoactive substance? If so, please explain... This will help us very much with your medicinal journey!*
Damage Liability: I agree to be financially responsible for any damage to property or equipment caused by my actions or negligence during the Activity.*

Yes I agreeNo I do not agree
PIease E-Sign your name below. 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 Signature at the top and Bottom 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 BUFO HEALING SANCTUARY sacred ceremonies; and if I am denied participation in an BUFO HEALING SANCTUARY ceremony due to my answers to the screening questions, that such a denial is based on BUFO HEALING SANCTUARY 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 Bufo Healing Sanctuary Waiver of Liability form. I hereby warrant and represent that I am of sound mind and body, and that it is my belief I am mentally and physically fit to participate in an Bufo Healing Sanctuary sacred ceremony, notwithstanding its staff's determination as to my fitness to participate.*
Should be Empty:

Step #1.

Step #3 Medical Questionnaire