Sensorium: Participant Intake &  Liability Release

Your privacy is paramount to us.

Any information provided in this form will be treated with the utmost confidentiality and utilized solely by our facilitators to offer you the best possible support.

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Email *
First + Last name *
Phone Number  *
Date of Birth *
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Please include the name and phone number of an emergency contact
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Have you experienced a sound meditation before?
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How did you hear about this ceremony?

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What is your experience with plant medicines and/or psychedelics? Please note if they have been recreational or ceremonial. 

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What intention(s) do you have for this journey?
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Please state any allergies or eating restrictions. We will serve a light meal at the end.
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Are there any scents you have an aversion to or are allergenic to?  (i.e. peppermint, rose, etc.)

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Do you consent to receiving gentle healing touch and energy work throughout the sensorium experience? (we’ll ask in person as well and you’re welcome to change your  mind)

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Medical Information
In the last 6 months have you taken any medications for depression, anxiety, schizophrenia, bipolar disorder, or ADHD? If so, please list the medications, the reason for taking them, dosage, and frequency.
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Does your medical history include any of the following? Check all that apply. These will not automatically disqualify you from participation, but it will warrant a follow up to ensure safety.  *
Required
Are you pregnant? *
Are you breastfeeding? *
Liability Release

Liability Release: I acknowledge that some activities during the event carry inherent risks and might not be safe for all participants. Participation is especially not advised for persons with or has had a history with any of the above medical conditions.

I hereby state that either none of the above conditions apply to me or, if they do apply to me, I have been cleared by a doctor to participate or will not participate.

I understand the hosts are not qualified to evaluate my fitness for participation in the event, and that I am fully responsible for seeking medical help to treat all symptoms that are present before and after the event.

I acknowledge that participation in all of the activities during the event is done so with my own digression and my own sovereign consent. 

IN CONSIDERATION OF MY PARTICIPATION IN THE EVENT, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS THE HOSTS AND THEIR RESPECTIVE AGENTS FROM ANY LIABILITY WHATSOEVER. I knowingly waive any claim I may have against the hosts for injury or damages that I may sustain as a result of participation. I assume the risk of injury or harm, and agree that my involvement in all the activities of the event is purely voluntary, including the ingestion of any substances.

I acknowledge that all contributions of proceeds are final and there are no refunds.

TYPE YOUR FULL NAME AS AN ELECTRONIC SIGNATURE 
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In order to have a safe ceremony, I agree to communicate leading up to the ceremony if I have any symptoms of illness or come in contact with anyone with these symptoms.
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In order to honor the sacred ceremonial container, I agree to stay on site for the entire duration of the experience, until completion of ceremony. *
Is there anything else you would like the facilitators to know?
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