By filling out the form below I affirm that:

I seek to participate in Ayahuasca Ceremony(ies). I understand that the facilitators desire to ensure the safety of all participants. I further understand that in order to assist in this regard, I agree to complete this application form and the Confidential Medical History Form. I am assured that the information obtained herein is used to determine if it is appropriate for the undersigned to participate in this work.

I further understand all information contained herein will remain strictly confidential.

The information provided in the form belowÃÂ is a complete and accurate statement of the physical and psychological factors which may affect my participation in the Ceremony.

I realize that failure to disclose such information now, and failure to provide update of any changes in the future, could result in serious harm to me and fellow participants and I agree to indemnify and hold harmless the facilitators if all relevant information is not disclosed.

I also agree to notify the facilitators should there be any change in the information provided or in my health status during this Ceremony and before and during any subsequent Ceremony.

This release says that you know that participating in an Ayahuasca Ceremony may involve discomfort and unexpected physical, mental or emotional upset. By signing this release agreement you are waiving all rights to seek or receive compensation in case of injury, loss or damage. *

I understand that, although my participation in an Ayahuasca Ceremony is purely voluntary, I agree to remain to the closing of a Ayahuasca Ceremony which I choose to begin. * During the Ceremony, I will ingest an entheogen known as Ayahuasca/Daime.

This substance is a natural extract of plants which grow throughout the Amazon Basin in South America. I have been informed of its effects, as well as, the objectives of taking it within the ritual led by experienced Ayahuasca leaders.

I have been attracted to the Ceremony as a result of research, personal reports, and information as well as the potential for a profound spiritual experience. I understand that the facilitators will make no claim or promise regarding the curing of any illness or the nature of any spiritual experience.

I understand that the Ceremony is personal and sacred to each individual and that what may occur for one person, may not necessarily lead to the same experience in others. *

I understand that the Ceremony in which I choose to participate may be physically, mentally, emotionally, or spiritually demanding. I understand that I may experience dizziness, nausea, or other physical upsets including vomiting and diarrhea. I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional mental changes. I acknowledge that the risks and potential benefits of my participation have been explained to me and I freely choose to enter this process accepting full responsibility for whatever may occur, anticipated or unanticipated.

I understand I may be physically or mentally exhausted and/or disoriented after a Ceremony. I acknowledge that it is my responsibility to arrange alternate transportation, if needed at the conclusion of a Ceremony.
I hereby acknowledge and voluntarily assume the full risks of any physical or other injury, damage or losses, either to myself or caused to others by me during any Ceremony organized by or held on the property of the facilitators. I hereby waive the liability of and agree to hold harmless the facilitators, including all of its founders, members, associates, employees, agents, staff, family, successors, volunteers, any and all property owners where the Ceremony occurs, and other participants. I further agree to defend and indemnify them from any claims, suits or demands. I understand that this agreement is binding upon me, my spouse, parents, family, heirs, executions, administrators, agents and assigns.

* I agree that each and every provision of this agreement is independent of any other provision and may be enforced even if other provisions are not enforceable.

I HAVE READ AND UNDERSTAND THIS WAIVER, HAVE HAD TIME TO REFLECT UPON IT, AND SIGN THIS WAIVER VOLUNTARILY.