Event Registration

1
Name* This field is required.
First Name
Last Name
2
Birthdate* This field is required.
Date
Year
Month
Day
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
How did you find out about this event?* This field is required.
6
Have you participated in an ayahuasca ceremony before?* This field is required.
YESNO
7
If you answered yes to the above question, briefly describe your experience.
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8
What has inspired you to take ayahuasca? What are you hoping to address, heal, and/or learn?* This field is required.
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9
Please list any pharmaceutical medications you’re taking, especially for a heart condition, SSRI’s, ADHD meds, or anti-psychotics.* This field is required.Please note: you will NOT be automatically excluded if you’re on any contraindicated medications, but we will reach out for a 1:1 call to discuss your options
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10
Do you have any health issues that we should know about? * This field is required.Example: fainting, seizure disorder, etc
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11
Do you have any health limitations, physical injuries, mobility limitations, or anything else that’s important for the team to know?* This field is required.We will do our best to comfortably accommodate you
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12
Do you agree to follow the dieta for at least 1-2 weeks prior to ceremony?* This field is required.A detailed list will be provided, and includes refraining from red meat, caffeine, alcohol, drugs (including cannabis), sugar, and sexual activity (solo and partnered)
YESNO
13
Do you agree to attend all Zoom meetings relating to the ceremony?* This field is required.This includes one pre-ceremony meeting, and 3 integration sessions following the ceremony
YESNO
14
Is there anything else you’d like us to know?
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