Disclaimer

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Disclaimer

Please fill out the form below. No payments will be accepted until this form is submitted. Once the form is submitted and reviewed, we will then set a call for next steps in working together. If some reason you are not currently a good fit, we will reach out and discuss next steps.

Please answer all questions completely and honestly in order to ensure safety. By filling out this form you agree to assume any and all risk involved in the process of working together. This form includes your personal information necessary for preparation as well as necessary and non-negotiable requirements to receive services.

By clicking "I Agree" in the boxes regarding abstinence time from substances you are agreeing that you will not partake before or after the in person ceremony and that if you do you assume all risk. Failure to disclose usage or inaccuracy in filling out this form can be dangerous.

Email *

Full legal name *

Date of birth (Must be 18+ years old to participate) *

YYYY

Phone Number *

Email Address

Emergency contact name, relation, and phone number *

Where did you first hear about us?

Please check any boxes that currently apply to you or would. Please mark if you have EVER taken any of the below and we will discuss.

Immune suppressant medications for an autoimmune disorder or organ transplant

Low blood pressure medication - designed to raise blood pressure (e.g. Midodrine)

Diuretics

Anti-Epileptics

Anti-Psychotics

Fentanyl

Heroin Substitutes - Methadone, Buprenorphine, Naltrexone

Krokodil (Desomorphine)

Pink (U-47700)

Please check any boxes that apply to you currently or in the past.

Have you ever seen a cardioloogist?

Arrhythmia, Heart Failure, Coronary Artery Disease

Elhers Danlos syndrome

Marfan syndrome

Addison’s Disease (Adrenal Insufficiency)

Stroke

Brain hemorrhage/aneurism/blood clots

Lack the mental capacity to make the decision to take Kambo

Serious mental health problems excluding depression, PTSD and anxiety

Have experienced any sort of psychosis - hallucinations/delusions

Currently undergoing chemotherapy, radiotherapy or have in the past 6 weeks

Epilepsy

Recovering from major surgery

Under 18 years old

Bufo ceremony in the last 6 weeks

Pregnant or breastfeeding a child

Consumed other strong medicines (eg. San Pedro, Ayahauaca, Psilocybin) within 24 hours of wanting to receive Kambo

Over 70 years old

Received a Covid-19 vaccine within the past 4 weeks

Please review the below list of substances and check any that you have taken in the past 3 months. We will discuss these more in-depth over the phone. Please be completely honest.

Alcohol High Doses

Alcohol Low Doses

Amphetamines Including Adderall and Ritalin

Anti-Depressants and Anxiety Medication including Duloxetine/Cymbalta

Ayahuasca

Benzodiapines e.g. Valium, Diazepam

Beta Blockers

Blood Thinners

Botox

Bufo, 5-meo dmt

Cannabis

Cocaine

Coca Leaf

Codeine

Crack Cocaine

Ecstacy (MDMA), Molly or similar

GHB

Heroin (recreational)

High Blood Pressure Medication (anti-hypertensives)

Iboga

Ketamine

LSD

Meth Amphetamine

Morphine / Oxycodone

N, N-DMT

Nitrous Oxide

Peyote, San Pedro (Mescaline)

Psilocybin

Research Chemicals, SPICE, Bath Salts, Mephedrone, Synthetic cannabinoids, etc.

Tramadol

Vasoconstrictors (Triptans)

2CB

Covid Vaccine or booster

Empowered LLC "Services" Release of Liability and Assumption of Risk Agreement and Disclaimer:

Your facilitator is not a licensed medical professional and does not diagnose or prescribe any medications for conditions, nor do they claim to treat or cure any medical conditions. Services should not be used as a substitute for medical care or advice from a licensed physician. Please contact a qualified, licensed physical for diagnoses and treatment of any medical or mental health conditions.

In consideration for being allowed to participate in the Services you agree to the following:

1. AGREEMENT TO FOLLOW DIRECTIONS. I agree to follow any oral instructions or directions given by the practitioners and representatives throughout the entire in person sessions.

ASSUMPTION OF THE RISKS AND RELEASE. I recognize that there are certain inherent risks associated with the above-described activity and I assume full responsibility for personal injury to myself and further release and discharge anyone working under or with Empowered LLC including the LLC itself from responsibility for injury, loss, or damage arising out of my use of or participation in any services provided by Empowered LLC, whether caused by myself, other participants, or anyone from Empowered LLC.

3. FEES. I agree to pay for all damages to any facility in which I partake of Empowered LLC services, caused by any negligent, reckless, or willful actions by myself. I agree to pay for services rendered in full before the administration or participation in any services with Empowered LLC. If I choose to discontinue or not participate in services after they have begun or I decide I am unsatisfied with the results, I acknowledge that there are no refunds or discounts given and I assume the loss of funds. Any and all payments are NON-REFUNDABLE.

4. APPLICABLE LAW. Any legal or equitable claim that may arise from participation in the above shall be resolved under the law of the state in which Empowered LLC and Melissa Tarryk are currently residing.

5. NO DURESS. I agree and acknowledge that I am under no pressure or duress to sign the Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire. I further agree and acknowledge that Empowered LLC has offered to refund any fees I have paid to use its services and facilities if I choose not to sign this Agreement.

6. ARM'S LENGTH AGREEMENT. This Agreement and each of its terms are the product of an arm's length negotiation between the Parties. In the event of any ambiguity is found to exist in the interpretation of this Agreement, or any of its provisions, the Parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction either "for" or "against" a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity.

7. ENFORCEABILITY. The invalidity or unenforceability of any provision of this Agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this Agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this Agreement.

8. DISPUTE RESOLUTION. The Parties will attempt to resolve any dispute arising out of or relating to this Agreement through friendly negotiations amongst the parties. If the matter is not resolved by negotiation, the parties will resolve the dispute using the below Alternative Dispute Resolution (ADR) procedure. Any controversies or disputes arising out of or relating to this Agreement will be resolved by binding arbitration under the rules of the American Arbitration Association. The arbitrator's award will be final, and any judgement may be entered upon it by any court having proper jurisdiction.

9. INDEMNIFICATION. I, for myself and on behalf of my heirs, assignees, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY (reimburse for any loss including any reasonable legal fees that may incur), AND HOLD HARMLESS THE ORGANIZER AND PRACTITIONER, their officers, officials, agents, and/or employees, other participants, and, if applicable, owners and lessors of premises used for the Coaching/Mentorship sessions ceremony ("RELEASED PARTIES"), with respect to any and all injury, disability, death, or loss or damage to person or property, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASED PARTIES OR OTHERWISE, to the full extent permitted by law. I KNOWINGLY AND FREELY ASSUME ALL RISKS, both known and unknown, EVEN ARISING FROM THE NEGLIGENCE OF THE RELEASED PARTIES or others, and assume full responsibility for my participation.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, I FURHTER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.

Required

SIGNATURE: By completing this form you are consenting to the use of your electronic signature in lieu of an original signature on paper.

Participant's Full Legal Name

A copy of your responses will be emailed to the address you provided.

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