Cacao Communion Registration Form

Cacao Communion Registration Form
Hello! Thank you for your interest in joining us for Cacao and Rosa Comunion and Sacred Smoke Limpia in Roserburg, Oregon!

Please note that we are in a very small space with limited capacity. I will do my best to monitor registrations and close these as soon as the space is filled. If, for some reason, I miss this window, I will promptly refund you and add you to our waitlist for the next gathering.

Once you are registered, I will follow up with an email, a phone call, and will provide the venue address and other logistical details. It is my intention to keep this space small, sacred, and safe for all participants, which is why I need to make sure I know who is joining us.

I look forward to being in this sacred container with you!

In gratitude,

Maribel
Name

First NameLast Name
Pronouns
How do you identify (race, ethnicity, gender, orientation, etc.)
Email*
example@example.com
Telephone (Needed in order to connect for logistics and screening)*
example@example.com
Is there anything you would like to share about yourself and/or your interest in this offering?
Have you ever worked with Cacao as a sacred medicine before?
Do you have sensitivity to caffeine? (Cacao contains Theobromine, which is a stimulant)
Do you have any physical or mental health conditions at this time? If so, can you please explain what these are?
Do you have any food or other allergies? If so, please list them?
I understand that Cacao and other stimulants (like Coffee) can cause an increase in heart rate and blood pressure. I am choosing to ingest Cacao brew at my own discretion. I will not hold Maribel Ramirez and/or Liberation Pathways LLC responsible for any issues that might arise from my ingestion of Cacao or any aspect of my experience as it pertains to this offering. I understand that this communion might support my wellness, but is not mental health therapy. Participation in this offering is not a substitute for mental or physical health care of any kind, nor does it mean that I am in a therapeutic relationship with Maribel Ramirez and/or Liberation Pathways LLC. I understand that if I am struggling with mental or physical health issues, I'll go through the appropriate medical channels.*

Yes
Signature*

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PLEASE SUBMIT $15 REGISTRATION FEE USING THE SCAN CODE BELOW. YOU CAN ALSO EMAIL ME AT WELCOME@MARIBELRAMIREZ.LIFE TO SUBMIT PAYMENT ANOTHER WAY. YOUR REGISTRATION FEE SECURES YOUR SPOT.
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Cacao Communion Registration Form

PLEASE SUBMIT $15 REGISTRATION FEE USING THE SCAN CODE BELOW. YOU CAN ALSO EMAIL ME AT WELCOME@MARIBELRAMIREZ.LIFE TO SUBMIT PAYMENT ANOTHER WAY. YOUR REGISTRATION FEE SECURES YOUR SPOT.