REVIVE Alignment Application

Alignment Application

REVIVE Retreat by Pura Vida Collective
With gratitude, we welcome you here. All of you is welcome.

This Alignment Application helps us prepare a safe, well-supported container for your REVIVE Retreat experience and is required prior to each retreat, even for returning participants. All responses are kept confidential and private.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Is your phone number linked to WhatsApp?*

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Activity Waiver & Release

This section is a standard part of creating a safe, respectful container. It outlines our shared expectations (honesty, consent, and code of conduct), clarifies that participation is voluntary, and documents informed consent. It also helps us name boundaries and intolerable offenses so everyone understands what safety and respect look like in practice.
THIS ACTIVITY WAIVER & RELEASE (this "Agreement"), (the "Participant") AND Pura Vida Collective (the “Organizer”)

IN CONSIDERATION OF the covenants and agreements contained in this Agreement and other good and valuable consideration, the receipt of which is hereby acknowledged, the parties to this Agreement agree as follows:

Consideration

1. The Participant, being of lawful age and having thoroughly reviewed the potential challenges and benefits of medicine use, hereby releases and discharges forever the Organizer and the Organizer's affiliates, including but not limited to their spouse, heirs, executors, administrators, legal representatives, and assigns, from all forms of actions, causes of action, debts, accounts, bonds, contracts, claims and demands for injury to person or property, including injury resulting in the death of the Participant, which may be sustained as a result of the Participant's participation in the activities described below, regardless of whether such damage, loss, or injury was caused solely or partly by the negligence of the Organizer.

2. The Participant understands that participation in the activity described below would not be permitted without signing this Agreement.

Details of Activity
The Participant may partake in the following activities at a Pura Vida Collective (event) in Costa Rica:
- medicine ceremony
- sound journey, breath-work, and meditation
- workshops, classes, and guest lectures
- leisure time and time in nature
- meals and snacks

The Participant will also partake in the Preparation/Integration Program with the Preparation/Integration Support Team, which includes all resources, online communities, and services offered, such as:
- medical intake call
- preparation (intake) call
- integration call
- online community and resources
- any additional 1-on-1 services coordinated between the guest and the preparation/integration support team.

Code of Conduct
During their time at a Pura Vida Collective (event), the participant agrees to abide by the following rules and stipulations:

The Golden Rule of “Respect”
1. Respect the medicine and the traditions
2. Respect and follow directions and guidelines provided by the Organizer facilitation team
3. Respect the healing process of oneself and others in the group
4. Respect the personal boundaries of others in the group
5. Respect that everyone has their own unique experience and deserves space, peace, and quiet

*** Important: Please refrain from talking with or touching other people during ceremonies. ***

6. Respect all guests and staff. Note: We maintain a zero-tolerance policy against sexual harassment.
7. Engaging in sexual activity, including with oneself or even between married couples, is prohibited during events.

Violation of any of these rules may result in a warning or immediate expulsion from the event without reimbursement, at the discretion of a member of the facilitation team.

The Intolerable Offenses
1. Sexual harassment towards guests or facilitators, including verbal/non-verbal insinuation and direct physical contact.

2. Behavior that puts your own or others’ safety at risk, including carrying travel tools such as pocket/utility knives.

3. Persistent disruptive behavior inside or outside of ceremony that discomforts other guests or significantly interferes with their healing process.

4. Leaving the ceremony before it concludes, whether or not you have partaken in ceremonial medicine.

5. Bringing any form of recording equipment, including a mobile phone, into the ceremony, unless agreed to with the Organizer.

6. Usage of any substances recreational or otherwise, without the explicit consent of the hosts and/or lead facilitator, including painkillers, anti-diarrhea or any other medication, plant or pharmaceutical.

7. Leaving the ceremony without prior arrangement or explicit consent from the Organizer.

The Participant agrees that violating any of the above intolerable offenses could result in immediate expulsion without question and without refund, entirely at the sole discretion of the Organizer. Any additional travel fees incurred will be the responsibility of the participant.
I have read and agree to the Activity Waiver and Release above.

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Signature

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Readiness & Safety Agreement

These agreements support safety, clarity, and the integrity of our shared container. By completing this section, you confirm honest disclosure of any known physical or mental health considerations that could affect participation, and your commitment to follow retreat safety guidelines (including abstaining from non-approved psychoactive substances). This supports informed consent and shared responsibility.
1. All known physical limitations, medical ailments, and physical or mental disabilities have been fully disclosed. If required, the Participant has or will obtain a medical examination and clearance prior to arrival.*
2. Participant will abstain from all other psychoactive substances during their stay, including but not limited to: prescription medications, recreational drugs, or other plant medicines/psychedelics (unless explicit consent is given by the lead facilitator).*
3. Participant is currently NOT taking or have not taken any medication (including SSRIs and MAOIs) for the past four weeks that were not explicitly known and approved during the intake process.*
4. Participant does not have any preexisting heart ailments, and any respiratory ailments (e.g., asthma) have been cleared by the Organizer.*
5. Participant does not have any preexisting mental health conditions such as Bipolar Disorder, Schizophrenia, Seizures or Psychosis.*
6. Participant accepts all risk associated with the consumption of medicines offered by the Organizer.*
7. Participant understands that there are inherent risks of being in a wilderness environment that may cause injury or death.*
8. Participant acknowledges that they may feel worse (mentally, physically, emotionally) during or after as part of their process working with medicine.*
9. Participant acknowledges that the Organizer cannot accept responsibility for theft or damage to belongings.*
10. In the unlikely event of a psychotic episode or adverse reaction to medicine, Participant agrees that the Organizer reserves the right to offer care and emergency protocol as deemed fit by the facilitation team, with the support of the next of kin or the emergency contact. This may include, but is not limited to, the use of anti-psychotic medication, the ability to retain the guest onsite for monitoring beyond the end of their retreat, and liaising with local emergency medical and hospital facilities.*
11. The Organizer reserves the right to expel any guest without prior notice, responsibility for a refund, or providing accommodation outside of the retreat center. Should a Participant decide to leave a workshop prematurely, for any reason, the Organizer is not responsible for the reimbursement of monies or for any denouncements by the attendee.*
12. If a person decides to leave before the end of ceremony while they are under the influence of the ceremonial medicine, the Organizer is not responsible for any accidents, injuries or death as a result of you departing early.*
13. If the Participant has provided incorrect information or obscured details, they understand that they may be endangering themselves and others. In such cases, they can be expelled from the event without question and without refund at the sole discretion of the Organizer.*
14. The Organizer is not responsible for any decision made by the Participant to stop taking medication or for changing their medication schedule. The Organizer accepts no liability for any adverse effects from doing so. The Participant acknowledges that the Organizer has advised them to seek medical advice and/or supervision from their prescribing doctor before reducing, ceasing, or changing any medication.*

Informed Consent, Release & Hold Harmless

This section confirms you’ve read and understood the agreements above, including informed consent, disclosure of relevant health information, and the release/hold-harmless terms for Pura Vida Collective. It also clarifies responsibility for any costs that may arise if emergency medical support, supplies, or transportation are needed. You’re encouraged to review carefully and seek independent legal advice if desired.
1. The Participant acknowledges and agrees that they have carefully read this Agreement, that they fully understand its content, and that they are freely and voluntarily executing the same.

2. By signing this Agreement, the Participant agrees to be forever prevented from suing or otherwise claiming against the Organizer, Pura Vida Collective and it's facilitators and the retreat venuem it's owners for any property loss or personal injury that they may sustain while participating in or preparing for the noted activity.

3. The Participant affirms that all medical information provided to the Organizer, Pura Vida Collective and its associated facilitators is true, accurate, and complete. The participant further agrees that they have not omitted any medical information that could deem them ineligible to receive the medicines offered during the jungle medicine ceremonies.

4. If the Participant is found to have lied or omitted any medical information, they acknowledge and agree that the Organizer, Pura Vida Collective and its associated facilitators reserve the right to take legal action against them for any damages incurred as a result. This includes, but is not limited to:

   - Medical emergencies resulting from undisclosed health conditions and any associated fees for emergency services and hospitalization.

   - Increased insurance costs due to incidents caused by false information.

   - Legal fees and costs associated with defending against claims or pursuing litigation related to the false information.

   - Operational disruptions and associated financial losses.

   - Reputational damage to Pura Vida Collective, its facilitators, and the retreat venue.

4. The participant agrees to indemnify and hold harmless the Organizer, Pura Vida Collective, its facilitators, and the retreat venue from any and all claims, damages, or liabilities arising from the participant’s provision of false or incomplete medical information.

5. In the event that the Organizer, Pura Vida Collective needs to obtain medical supplies or arrange transportation due to false or misleading information provided by a Participant, the Participant agrees to reimburse the Organizer for these expenses.

This reimbursement may include:

The cost of medical supplies, including any additional costs incurred to expedite procurement and delivery. An administrative fee for any staff travel required to obtain or deliver medical supplies or to provide transportation for the participant.

3. The Participant has been given the opportunity and has been encouraged to seek independent legal advice prior to signing this Agreement.

4. This Agreement contains the entire agreement between the parties to this Agreement and the terms of this Agreement are contractual and not merely a recital.

Governing Law

This Agreement will be interpreted in accordance with and governed by the laws of Costa Rica and the United States of America. The Participant has affixed their signature below prior to the start of their participation in any ceremony, event, retreat or workshop with the Organizer, Pura Vida Collective.
Signature of Participant

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Date Signed

MonthDayYear
Date

Medical Information Authorization

This authorization supports safety and informed consent. In the unlikely event of a medical concern or emergency, it allows us to request relevant medical information to support appropriate care. Most participants will never need this to be used. Its purpose is to reinforce honest disclosure and shared responsibility so we can hold the safest possible container.
Paitent Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Recipient Information
I hereby authorize the release of my medical records to:

Name/Organization: Pura Vida Collective and it's facilitators

Address: Tamarindo, Costa Rica

Phone: +50664255460

Email: susan@puravidacollective.com
Purpose of Disclosure
The purpose of this disclosure is:
- Legal Purposes
- Personal Use
- Retreat Safety
Information to be Disclosed:
I authorize the release of the following medical records:
- Entire Medical Record
- History and Physical Examination
- Progress Notes
- Laboratory Results
- Radiology Reports
- Medication Records
- Immunization Records
- Operative Reports
Dates of Service:
- All Dates
Authorization and Consent:
I understand that my medical records may contain information related to my medical history, diagnosis, treatment, and prognosis, as well as information regarding mental health, substance abuse, HIV/AIDS, and other sensitive information. I authorize the release of this information as specified above.

I understand that I have the right to revoke this authorization at any time by providing a written notice to the medical provider. However, the revocation will not apply to information that has already been released in response to this authorization.

I understand that once the information is disclosed, it may no longer be protected by federal privacy regulations and may be subject to re-disclosure by the recipient.
This authorization will expire one year after the ceremony/retreat date of:

MonthDayYear
Date
By signing below, I acknowledge that I have read and understand this authorization, and that I voluntarily agree to its terms.
Paitent Signature

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Date

MonthDayYear
Date
Should be Empty:

Alignment Application

Gentle note: Feel free to move through this at your own pace.

Emergency Contact Information

Activity Waiver & Release

Readiness & Safety Agreement

Informed Consent, Release & Hold Harmless

Medical Information Authorization

Paitent Information

Recipient Information

Purpose of Disclosure

Information to be Disclosed:

Dates of Service:

Authorization and Consent: