RELEASE + REMEMBER 2024
Please fill out this form to apply for the November 8-11 2024 retreat with Aryn and Emily.  Safety is our #1 priority, and your honest and confidential responses in this application form help us to maintain a safe and healthy retreat.  

Answer all questions accurately and to the best of your knowledge and ability.  All information will be kept confidential (for Aryn & Emily's eyes only) and helps us to better serve you.  We will review your submission and reach out to you shortly if we think it's a good fit for this experience.  Thank you for your interest, and we look forward to speaking with you soon!
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Email *
Full Name (and preferred pronouns if any) *
Will you be driving to Saugatuck, MI? *
What's your email address? *
Age *
Phone Number *
Where did you hear about this offering? *
What is your Facebook/Instagram handle?  (please provide direct link if possible)
Please describe your experience (if any) with entheogens/psychedelic medicines. *
Have you ever been diagnosed with any psychiatric conditions?  Please elaborate. *
Any family history of mental disorders?  If so, please list and briefly describe. *
Please list any physical conditions or health issues you have, if any.   *
Please list any and all medications and supplements you are currently taking (and specify frequency & dose). *
Please list any allergies and dietary restrictions you have, if any. *
Please list any other significant health information (e.g., chronic illnesses, surgeries in the past 18 months, etc). *
Do you use any recreational drugs (more than 1x/month)?  (E.g., alcohol, caffeine, nicotine, cannabis, etc)  *
Required
If you answered "yes" or "rarely" please specify (no judgment) *
Do you attend therapy and/or a support group? *
Do you have any resources for integration/support after working with this medicine?  Please explain. *
Are you pregnant or breastfeeding? *
How would you describe your relationship with spirituality and/or ceremony? *
Why do you want to join us for this retreat? *
Emergency contact name *
Relationship *
Their Phone Number *
I have answered all questions accurately and to the best of my ability.  I have disclosed all medical information. *
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