Our Health Form

Your Full Name *

Your Email Address *

Phone Number *

Emergency Contact Name (someone NOT attending ceremony) *

Emergency Contact Phone Number *

I'm planning on attending on the Tea Ceremony?*

Medication or response required for allergic reaction:

Antidepressant Use (in the last 6 months): *
YesNo

I understand that if I have used any SSRI antidepressants within the last 6 weeks I will not be able to attend ceremony: *
Yes, I understand

Addictions: *
YesNo

Substance-abuse Addictions (If any substance-abuse addictions were noted above, please note each substance in the box below and the date last used. If no substance-abuse addictions were listed above, please type "NA" in the box below. ***Please keep in mind that this information will be kept private and confidential.***): *

Have you experienced a Recent Illness, Cold, or Flu in the Last Two Months? *
YesNo

If Yes, please explain:

Have you had a Recent Accident? *
YesNo

Have you had a Recent Operation? *
YesNo

Have you had a Recent Hospitalization? *
YesNo

Do you have Asthma? *
YesNo

Will you be bringing emergency medication for asthma that you didn't list above?
YesNo

Do you have Diabetes? *
YesNo

Will you be bringing emergency medication for diabetes with you that is not listed above?
YesNo

Please just put the numbers, we'll assume it's in pounds: *

Do you have High Blood Pressure? *
YesNo

If you indicated yes, please explain your situation:

Are you taking any medication for high blood pressure?
YesNo

Do you have Low Blood Pressure? *
YesNo

Have you ever used any antihypertensive medications? *
YesNo

I understand that if I have used certain Antihypertensive Medications I will not be able to participate in Ceremony: *
Yes, I understand

Have you ever had Cardiac Failure or a Stroke? *
YesNo

Do you have any Bone, Joint, or Muscle problems? *
YesNo

Do you have a history of Seizures or a Seizure Disorder? *
YesNo

Do you have a history of Psychosis, Multiple Personality Disorder, Bipolar Disorder or Schizophrenia? *
YesNo

Do you have any other Mental Health Conditions not listed above? *
YesNo

Have you had Gastric Bypass Surgery? *
YesNo

Are you, or could you be, pregnant? *
YesNo

Do you have any other conditions that are not listed? *
YesNo

Do you have any Physical or Mental Limitations that could affect your ability to safely attend Ceremony? *
YesNo

Medical Release: Please read and review before checking below *

In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event’s leader, organizers and participants from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted. To the best of my knowledge, I am in good physical condition and I am not aware of any physical and physiological infirmity, which would place me at risk to participate in any way with the ceremony activities. I am fully aware of the risks and hazards connected with this event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE, ILLNESS, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. By selecting "Yes, I accept the terms of this Medical Release Statement" below, I am acknowledging and representing, in the same way that a signature would represent, that I have read and understand this Medical Release Statement and sign in voluntarily; I am least eighteen (18) ears of age and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same.

Yes, I accept the terms of this Medical Release StatementNo, I do not accept the terms of this Medical Release Statement

PARTICIPATION AGREEMENT, WAIVER AND RELEASE OF LIABILITY *

By confirming my agreement to this waiver, I acknowledge that I have carefully read this document and fully understand its terms and conditions and that this is a release and waiver of all liability with regard to any rights I may have to seek compensation in the case of any loss, damage, illness, or injury, including death. I acknowledge the ceremonies I plan to participate in as part of my religious practice, in exercise of my freedom of religion and under protections of the First Amendment of the United States' laws and Constitution. As part of these religious ceremonies, I will drink the Divine Yagé Sacrament and/or receive the Divine Kambô Sacrament, both of which are native to the Amazon Basin in South America. These Divine Sacraments will be consecrated and served in religious and spiritual practice guided in ceremony. I understand and acknowledge that no guarantee, claim or promise regarding the curing of any illness, the nature of any spiritual experience, and/or that I will receive any benefit from participating in the ceremony. I understand that the Ceremonies in which I voluntarily choose to participate may be physically, mentally, emotionally, and/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 and/or 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 hereby knowingly 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 of the Ceremonies. I am freely making monetary donations to help cover part of the expenses necessary to support the continuity of these Spiritual and Religious traditions for me and for future generations. I understand I may be physically or mentally exhausted and/or disoriented after the Ceremonies, and I acknowledge that it is my responsibility to arrange alternate transportation, if needed. I understand that although my participation in the Ceremonies is purely voluntary, I commit to follow all the instructions given during the Ceremony. I commit to stay in the Ceremonial space and at the Ceremony site until the end of the Religious service, and under no circumstances will I leave the premises, either on foot or by any vehicle before I am cleared by the Ceremonial guides to do so. I understand, acknowledge, and agree to the importance of the privacy of the Ceremony, its participants, and the observations made of others during the Ceremony, and agree not to share any of this information and/or observations with anyone. Any emotional or other process that I happen to observe in others during the Ceremony will be kept strictly confidential and I agree to abstain from photographing, filming, or recording anything throughout the duration of the Ceremonies I am present for. FOR GOOD AND VALUABLE CONSIDERATION, THE RECEIPT AND SUFFICIENCY OF WHICH IS HEREBY ACKNOWLEDGED, I DO HEREBY DISCHARGE AND COVENANT NOT TO SUE, AND RELEASE, HOLD HARMLESS, INDEMNIFY, AND FOREVER DISCHARGE THE CEREMONIAL GUIDES ORGANIZERS, MEMBERS, EMPLOYEES, AGENTS, STAFF, AFFILIATES, REPRESENTATIVES, CONTRACTORS, SUCCESSORS, ASSIGNS, RESPECTIVE HEIRS, PERSONAL REPRESENTATIVES, AND ALL PERSONS, FIRMS OR CORPORATIONS WHO MIGHT BE CLAIMED TO HAVE ANY LIABILITY, WHETHER OR NOT NAMED HEREIN (HEREINAFTER REFERRED TO AS “RELEASEES”), FROM ANY AND ALL LIABILITY FOR ANY LOSS, DAMAGE, EXPENSE OR INJURY, BOTH TO PERSON AND TO PROPERTY, INCLUDING DEATH, THAT I MAY SUFFER OR THAT ANY THIRD PARTY MAY SUFFER AS A RESULT OF MY PARTICIPATION OR IN ANY THIRD PARTY’S PARTICIPATION IN THE CEREMONY AND ANY OTHER RELATED ACTIVITIES, DUE TO ANY CAUSE WHATSOEVER INCLUDING NEGLIGENCE, GROSS NEGLIGENCE, BREACH OF CONTRACT, BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, AND/OR BREACH OF STANDARD OF CARE, ON THE PART OF THE RELEASEES, AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME OR OTHER THIRD PARTIES FROM THE RISKS, DANGERS, AND HAZARDS OF PARTICIPATION IN THE CEREMONY AND ANY OTHER RELATED ACTIVITIES. I understand that the ceremony organizers do not carry personal liability insurance that covers my participation in the Ceremony, and that I have the option to purchase such insurance. I understand and agree that this Waiver and Release of Liability Agreement shall be binding upon my heirs, next of kin, executors, administrators, assignees, representatives, trustees, and guardians in the event of my death or incapacity. I understand and agree that this Waiver and Release of Liability Agreement and any rights, duties, and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of the State of North Carolina and no other jurisdiction, and any litigation involving the parties to this agreement shall be brought solely within the State of North Carolina and shall be within the exclusive jurisdiction of the courts of the State of North Carolina. It is understood and agreed that this Waiver and Release of Liability Agreement is made in full and complete settlement and satisfaction of the aforesaid actions, causes of action, claims and demands and that this release contains the entire agreement between the parties. In entering this Waiver and Release of Liability Agreement I am not relying on any oral or written representations or statements made by the Releasees with respect to the Ceremonies and related activities other than what is set forth in this Waiver and Release of Liability Agreement. I give permission to the Ceremonial Guides and Organizers to seek medical or other services for any injury or emotional distress. To the best of my knowledge, I attest that I am in good physical condition and I am not aware of any physical and psychological infirmity that would place me at risk to participate in any way with the Ceremonial activities. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE, ILLNESS, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the Ceremonial activities, no matter the cause, anticipated or unanticipated. I agree to defend, indemnify, and hold harmless ceremony guides, and religious leaders, and its officers, directors, members, employees, agents, staff, affiliates, representatives, contractors, successors, assigns, respective heirs, and personal representatives from and against any loss, liability, claim, action, or demand, including without limitation reasonable legal and accounting fees, alleging or resulting from my participation in the ceremony or in any related activities. By selecting "Yes, I agree to the above terms," I am acknowledging and representing, in the same way that a signature would represent, that I have carefully read this document and fully understand its terms and conditions; that I have had time to reflect upon it; that this is a release of all liability; that I accept all of the terms of this agreement voluntarily; and that I am least eighteen (18) years of age and fully competent, and if I am not 18 years of age that I have signed approval below by a parent or guardian. I execute this Waiver and Release of Liability Agreement for full, adequate, and complete considerations and I fully intend to be bound by its terms.

Yes, I agree to the above termsNo, I do not agree to the above terms

Any questions, concerns, or additional information that you would like to report to us at this time: