Kambo-Bufo Training Application

Full name

First NameMiddle NameLast Name

Preferred name

Email

example@example.com

Phone / WhatsApp

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of birth

Date

Occupation

Instagram / social handle

Emergency contact name

First NameLast Name

Relationship to you

Emergency contact phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency contact email

example@example.com

Which training are you applying for?

Preferred In-Person Practical Training Location / Facilitator

Preferred training window / dates

Have you completed the preparatory online phase?

What draws you to becoming a Kambo/Bufo facilitator?

How do you feel called to use this training?

What does "knowing when to serve, how to serve, and when not to" mean to you?

Have you received Kambo before?

If yes, how many times and when was your last session?

Have you experienced Bufo before?

If yes, how many times and when was the last one?

Do you have experience with other plant medicines or altered-state practices?

Do you currently hold any certifications relevant to facilitation or healing work?

Do you have prior experience holding space for others (formally or informally)?

Commit to completing the required online preparatory phase before arriving in Tulum?

Accommodation is not included and I am responsible for arranging my own lodging

Meals are not included

Have you ever had an anaphylactic or severe allergic reaction to Kambo, Bufo, or an insect sting/venom?

Do any of these apply to you?

For any box checked, please give details

Mental health history

For any box checked, briefly note diagnosis and current status

Are you currently taking psychiatric medication?

List current medications (dose + duration)

Are you currently taking any other medications, or do you have known allergies?

Do you have any severe or life-threatening allergy requiring an EpiPen?

I understand a non-refundable deposit is required to secure my one private training spot

How would you prefer to handle payment?

All deposits are non-refundable but fully transferable to a future training date within 1 year. Remaining balances for all payment options must be paid in full before the start of the in-person training.

How did you hear about Esencia by GlendaLee?

If referred by someone, their full name

First NameMiddle NameLast Name

LEGAL AGREEMENTS

Please read the following before checking each box and typing your name below.

1. Acting on My Own Behalf — I attest that I am submitting this application for myself, all information provided is my own, and I am not applying on behalf of anyone else.

2. Health Screening & Full Disclosure — I have truthfully disclosed all conditions, supplements, and medications relevant to receiving Kambo and/or Bufo during this training, and I will report any changes before the training begins.

3. Not a Medical Service — I understand this training is not a medical service, and the facilitator is not a licensed physician, psychologist, or mental health professional.

4. Assumption of Risk & General Release of Liability — By checking the box below and typing my name, I acknowledge and agree to the following as a condition of my participation in the Kambo and/or Bufo Facilitator Training with Esencia by GlendaLee: (A) I voluntarily waive, release, and discharge Esencia by GlendaLee, Glenda Lee Nazario, assistants, property owners, and affiliates (collectively, "Releasees") from any and all liability, including but not limited to liability for death, disability, personal injury, property damage, or any other loss arising before, during, or after this training, except where prohibited by applicable law. (B) I agree to indemnify and hold harmless the Releasees from any claims arising from my participation, including from the hands-on, supervised practice sessions in which I will personally receive Kambo and/or Bufo. (C) I understand that Kambo may produce effects including but not limited to nausea, vomiting/purging, burns at the application site, swelling, and temporary changes in blood pressure or heart rate; and that Bufo/5-MeO-DMT may produce an intense, brief altered state, rapid changes in heart rate and blood pressure, disorientation, and emotional release. I voluntarily accept these risks as part of my training. (D) I affirm that I am physically and mentally prepared for this training, have disclosed all relevant health information, and have not been advised against participation by a medical professional. (E) I consent to receive emergency medical treatment if deemed necessary during the training, and understand I am solely responsible for any resulting medical expenses. (F) I understand this training involves practicing facilitation skills on and with other participants under supervision, and I voluntarily accept the risks inherent in that mutual practice. I certify that I have read and fully understood this waiver and agree to its terms willingly.

5. Confidentiality of Curriculum & Materials — I agree that all training manuals, scripts, and materials provided to me are proprietary to Esencia by GlendaLee, and I will not reproduce, share, or teach from them without written permission.

6. Confidentiality of the Training Space — I agree to keep confidential anything shared by the facilitator or any other participant during the training.

7. Cancellation & Deposit Policy — I understand my deposit is non-refundable, and I agree to the cancellation and rescheduling terms provided to me separately.

8. Agreement to Read All Communications — I agree to read all messages sent to me before the training, understanding they may contain required preparation steps.

By checking each box below and typing my name in CAPS, I confirm that I have read, understood, and agree to the corresponding section above.

Acting on my own behalf

Health screening & full disclosure

Not a medical service

Assumption of risk & release of liability

Confidentiality of curriculum & materials

Confidentiality of the training space

Cancellation & deposit policy

Agreement to read all communications

Name in CAPS

Signature

Date

Kambo-Bufo Training Application

Applicant Information

Emergency Contact

Training Selection and Background

Training Commitment and Logistics

Medical and Health Screening

Payment and Referral

Legal Agreements and Signature