Participation Form

CEREMONY PARTICIPATION FORM

The purpose of this participation form is for us to have all the necessary information to support and guide you on your journey. Working with powerful shamanic tools in particular requires observation. All information shared here will be kept strictly confidential and is there so that we can ensure the safety of you and all the participants. Please answer the questions as honestly as possible and give full disclosure of details requested. Also note that our sessions are neither psychological in nature nor are they a substitute for any kind of medical diagnosis, therapy or treatment. We require you to seek the advice of your doctor or qualified health practitioner if you have any medical or psychological concerns or conditions before attending our sessions.

First Name

Last Name

Date Of Birth

Mobile Numer

Mobile Number (Next of Kin)

If this is your first time, please let us know who referred you or how you found out about us.?

Which event will you be joining?

Date of the event you will be attending?

What is your previous experience with plant medicines or psychedelics in ceremony?

Are you taking any kind of medication? If yes, please explain which ones and what they are for.

Working with the Plant Medicines requires observation. In order to participate, please confirm if any of the below is applicable”

If you selected any of the above, please provide further information below:

Do you have any food allergies, intolerances or concerns? Please give details.

Are you currently pregnant or breast-feeding?

Do you have any mental or physical conditions or concerns that we need to be aware of?

What are your intentions and goals in participating in this experience?

Disclaimer(Required)

1. I understand that the shamanic work I will be participating in may include the use of traditional healing plants. I agree that 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.

2.To the best of my knowledge, I am in good physical condition and I am not aware of any physical, physiological, or psychological infirmity which would place me at risk to participate in any way within the ceremony activities.

3. I agree that if I have any mental or physical health concerns I will inform the facilitators immediately.

4. If I find myself unable to participate for any reason (health related or otherwise) I understand that I forfeit my full deposit and fee.

5. I take full responsibility for my own belongings and safe transportation to and from this event.

6. I agree that while I have the space to authentically express myself within the ‘container’, I agree to hold the agreements of container set by the facilitators. I understand that these agreements are there to ensure the safety and peace of mind of each person participating.

7. I understand that the facilitators reserve the right to deny my participation if they deem that it would be unsafe for me, or others, or for any other important reason. I agree to listen and follow all the instructions given by the facilitators.

8. I take full responsibility for any damage that I may cause to any facility that is used for the event.

9. I acknowledge that a 50% deposit must be made to confirm my booking. This amount is non-refundable should I cancel. The balance must be paid 48 hours prior to the event in order for me to participate, notwithstanding a payment plan arrangement with the organisers.

10. I understand that the facilitators reserve the right to cancel the event, should that happen, I will be fully reimbursed or given the opportunity to re-book for a later date.

11. I hereby RELEASE, WAIVE, DISCHARGE AND COMMIT NOT TO INSTITUTE LEGAL ACTION the facilitator, organisers and/or participants for any and all liabilities, claims and demands arising from or related to the event. I agree to participate with the purest intention of heart, promoting the health as well as the well-being of all participants.

12. In submitting this form I acknowledge and represent that I have read and understood the above and sign voluntarily; I excuse this release for full, adequate and complete release of liability.

Upon submitting this form, I hereby acknowledge that I have read, understand and agree to the Disclaimer above