Peru Pre-screen Page

Please tell us if you have any disease, pathological or functional problem not considered here.

ALL THE INFORMATION WILL BE KEPT PRIVATE AND CONFIDENTIAL.  NO INFORMATION WILL BE SHARED TO ANYONE BUT THE SHAMAN AND THE FACILITATOR SPEAKING TO THE SHAMAN. (you can ask for clarification of who will be dealing with your information at the end of this form)

By clicking the SEND FORM button on the bottom you agree to the following terms :

  • I understand that this event includes the use of traditional healing plants.
  • I always have a choice whether or not to participate, and I agree to take full responsibility for the choices I make involving this work, both during and after the event.
  • To the best of my knowledge, I am in good physical condition and I am not aware of any physical, physiological, or psychological conditions which would place me at risk to participate in any way within the ceremony.
  • I take full responsibility for my own belongings and safe transportation to and from the ceremony/workshop.
  • I understand that the facilitators and the Shaman reserve the right to deny my participation if they deem that it would be unsafe for me, or for others, or for any other important reason.
  • I agree to listen and follow the instructions given by the facilitators and the Shaman.
  • I take full responsibility for any damage that I may cause to the facility that is used for the ceremony.
  • To maintain the safety, trust and respect for all participants, I agree to hold this work confidential. I will not reveal to anyone the identity of those who are participating in the event. This includes maintaining confidentiality for all facilitators, helpers, shamans or healers who are also participating in the ceremony.
  • I agree to participate with the purest intention of heart, promoting the health and well-being of all participants.
  • I hereby RELEASE, WAIVE, DISCHARGE AND COMMIT NOT TO SUE the event leader, organizers and/or participants for any and all liabilities, claims, demands arising from or related to the event.
  • In signing this release (Clicking the Send Form button), I acknowledge and represent that I have read and understand the above and sign voluntarily; I excuse this release for full, adequate and complete release of liability.

    First Name (required)

    Last Name (required)

    Your Email (required)

    Your Phone Number (required)

    What do you do for a living?

    Age

    Sex
    MaleFemale

    Do you speak Spanish?
    YesNo

    Do you have any disease or special psychological conditions that could conflict with the Ayahuasca Tea? If yes, please, explain.

    Are you currently taking any medication? If yes, please, explain.

    Do you have any past experience with Ayahuasca Teas in a ceremony?
    Variations of Ayahuasca in sacraments or Vine onlyFirst timeHave been through La Dieta1-3 Ceremonies4-10 Ceremonies10 or more Ceremonies

    Have you been to ceremonies where you sat with and used sacraments or psychotropic plants? If yes, please explain?

    Do you have any problem or other questions not indicated in this questionnaire? If yes, please, explain.

    Would you like to be informed of future events?
    YesNo

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