Date of Retreat
Retreat: June 3 to 8th 2021, Valle de Bravo
Retreat Peru: June 28th to July 3rd 2021, Sacred Valley, Perú
Ceremony: April 24th, Valle de Bravo (nighttime)
Ceremony: May 1st, Valle de Bravo (nighttime)
Ceremony: May 15th, Valle de Bravo (nighttime)
Ceremony: May 22nd, Valle de Bravo (nighttime)
Paternal Last Name
Maternal Last Name
Date of Birth
Place of Birth
Psychiatric Disorders? ¿Which?
Other Diseases? Which?
Are you receiving some sort of treatment? Which?
Are you taking any medications? Which?
Do you (or have you ever) consumed alcohol or drugs?
Which? And with what frequency
Have you ever had difficulty stopping the consumption of alcohol or drugs?
Have you ever had any of the following experiences?
Have you ever participated in a ritual of some type of ancestral medicine
If you chose other....which?
How was your experience?
According to your own criteria...have you ever had some kind of important spiritual experience? What was it like?
What are your intentions in embarking on this journey with the medicine?
IMPORTANT! When you write your name in the field to sign and click on the SEND button on the medical form, you accept the following terms: p>
1. I understand that work in the retreat may include the use of traditional healing plants. P>
2. I agree that I always have the option to participate or not, and I agree to take full responsibility for the decisions I make regarding this work, both during and after the event. P>
3. To the best of my knowledge, I am in good physical condition and have no knowledge of any physical, physiological or psychological illness that puts me at risk of participating in any way in the activities of the ceremony. P>
4. I assume all responsibility for my belongings and safe transportation to and from the Retiro center p>
5. I understand that the facilitators reserve the right to deny my participation if they feel it would not be safe for me or others, or for any other important reason. P>
6. I agree to listen and follow the instructions given by the facilitators. P>
7. I assume full responsibility for any damage I may cause in the facilities used for the Retirement. P>
8. To maintain the safety, trust and respect of all participants, I agree to keep this work confidential. I will not reveal to anyone the identity of those who participate in the event. This includes maintaining the confidentiality of all facilitators, aides, shamans or healers who also participate in the Retreat. P>
9. I hereby release, waive and agree not to sue the event leaders, organizers and / or participants for any liability or claims arising out of or related to the event. P>
10. I agree to participate with the purest intention of heart, promoting the health and well-being of all participants. P>
11. I declare that the information presented in this registration form is true, that I do not use neuro-psychiatric medications, selective serotonin reuptake inhibitor (ISSR) antidepressants or monoamine oxidase inhibitors (MAOIs). and anticonvulsants. I have no history of psychotic outbreaks or previous psychiatric hospitalization. I assume total responsibility for my free participation in the ritual of working with the medicine known as Ayahuasca (obtained from cooking the Banisteriopsis caapi and Psychotria viridis plants), I have informed myself and I am aware of the effects that it may have on my body, as well like the substances, conditions and medications that are contraindicated. p>
12. By entering my name in the signature field of this press release (and clicking on the Submit button) I acknowledge and declare that I have read and agree to all the above information and that I sign voluntarily, completely releasing the organizers from liability and facilitators of the event. p>
Have you read the entire declaration from above
If you are human, leave this field blank.