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Registration form

𓋼𓍊 Sacred Ceremony 𓍊𓋼

Full Name *

Date of birth

YYYY

E-mail *

Phone number *

What is your motivation to participate? *

Have you done Mushrooms or other psychedelics before? If yes, tell me more about your experience! *

Dietary requirements *

None

Vegetarian

Vegan

Kosher

Gluten free

Other:

Questionnaire *

Yes

Do you have serious heart problems or have you had heart surgery? This includes a Pacemaker but excludes Stents.

Have you had a stroke or a brain haemorrhage?

Do you have an aneurism or history with blood clots?

Are you recovering from a major surgical procedure with internal stitches?

Are you on medication for low blood pressure?

Do you have mental health problems?

Have you had an organ transplantation?

Do you have epilepsy?

Do you have EDS?

Could you be pregnant?

Are you breast-feeding a baby under 6 months old?

Have you worked with Bufo Alvarius in the last 2 months prior to Kambo?

Do you use weight loss products, serotonin and/or sleeping pills?

Do you use immune suppressors for autoimmune diseases?

Do you have an alcohol or drug addiction?

Have you worked with Iboga in the last 90 days?

Are you planning to fast 7 days before or after the Kambo?

Have you recently had an enema, colon flushing, liver flushing or a water-based detox?

Have you had bulimia or anorexia?

Do you have diabetes?

Do you have astma?

Do you have liver or kidney problems?

Do you have an abnormal high or low blood pressure?

Have you understood all the above questions?

Yes

Do you have serious heart problems or have you had heart surgery? This includes a Pacemaker but excludes Stents.

Have you had a stroke or a brain haemorrhage?

Do you have an aneurism or history with blood clots?

Are you recovering from a major surgical procedure with internal stitches?

Are you on medication for low blood pressure?

Do you have mental health problems?

Have you had an organ transplantation?

Do you have epilepsy?

Do you have EDS?

Could you be pregnant?

Are you breast-feeding a baby under 6 months old?

Have you worked with Bufo Alvarius in the last 2 months prior to Kambo?

Do you use weight loss products, serotonin and/or sleeping pills?

Do you use immune suppressors for autoimmune diseases?

Do you have an alcohol or drug addiction?

Have you worked with Iboga in the last 90 days?

Are you planning to fast 7 days before or after the Kambo?

Have you recently had an enema, colon flushing, liver flushing or a water-based detox?

Have you had bulimia or anorexia?

Do you have diabetes?

Do you have astma?

Do you have liver or kidney problems?

Do you have an abnormal high or low blood pressure?

Have you understood all the above questions?

If you have entered 'yes' above (with the exception of the last question), please explain:

Is there another physical/psychological issue that has not been discussed and may possibly have an impact? *

Other:

Required

Have you used medication, drugs or supplements in the months prior to the Ceremony? If yes, enter what for and when (in the last three months) in 'other' so we can check the required minimum abstinence period prior to the ceremonies. *

Other:

Required

Would you like to do additional Kambo on Friday, Shamanic Healing on Friday and/or massage on Friday/Sunday? *

Yes I would like to receive Kambo on Friday the 1st of September (85€)

Yes I would like to receive a massage on Saturday the 2nd of September (1,5h 65€)

Yes I would like to receive a massage on Sunday the 3rd of September (1,5h 65€)

Yes I would like to receive a Shamanic Healing session on Saturday the 2nd of September (1h for 50€).

No thank you.

Required

Would you like to stay up to date about upcoming events?

Yes

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Cancellation policy

Once this form has been sent, you are registered as a participant and we count on your participation and exchange. If for some reason you are unable to participate, the following cancellation conditions apply: If you cancel up to 2 weeks before the retreat, you will receive a full refund. If you cancel within 7 days of the start of the retreat you loose €100 and will receive back the rest of the money. If the retreat is canceled, you will of course receive a full refund. I agree with this cancellation policy.

Disclaimer *

I understand that this retreat is not a substitute for medical care. The facilitators do not diagnose or prescribe treatments. Every mention of herbs or exercises is purely informative and the participant has his/her own responsibility to contact a care provider. I agree that I am responsible for my own health and that I do not hold the facilitators responsible.

I hereby declare that I have read everything and have completed this form truthfully.

Required

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