Yawanawá Cultural Experience
Thanks so much for taking the time to fill in this form. We ask for this information so we can know in advance of special medical conditions you may have prior to the retreat and ceremonies to determine is this is an appropriate path of healing. 

For your safety we will review this form, and may contact you to discuss anything that we may need to know more information about.

We keep the information on this form confidential. Only the organizers and / or others who know and understand its confidential nature will see it. The form will be retained along with your liability waiver for a period of time following the meetings, after which it will be deleted. 
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Legal Full Name (First, Middle and Last) *
Email *
Your preferred-to-be-called Nickname
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Your Phone Number

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Date of Birth
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Current Address:
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Emergency Contact Info:
(Name, Relationship to you, Phone Number + Email)
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How did you find out about this retreat? If a  friend told you, please share their name so we can send them some gratitude! *
What is your occupation? *
How do you enjoy spending your free time?
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What, if any, are your dietary restrictions? *
If you have any food allergies or other restrictions, please explain in the provided space. 
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If you have allergies to anything else (medicines, animals, insect bites and stings, environment: dust, pollen, etc.), please list below. *
Allergy Reaction Medication Required? (if any) 
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Do you have high/normal/low blood pressure? 
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Please list any prescription, over-the-counter, natural medications, or supplements you are currently taking. (name, dosage, frequency.) 
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Do you use Antidepressants, or Antihypertensive medications? If Yes, please explain name, dosage and frequency. *
Have you had any recent illnesses? Accidents? Surgeries/Operations? Hospitalizations? *
Do you have asthma?
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Do you have diabetes?
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Do you have a history of cardiac failure or stoke?
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Do you have any bone, joint, or muscle problems/concerns?
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Have you ever had a seizure? If Yes, please explain.
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Do you have or have you ever experienced psychosis, schizophrenia, bipolar condition, or psychological instability? *
Do you have a history of depression?
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Are you pregnant, or think you could? 
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Has your doctor ever told you if you have a genetic or medical condition that would prohibit the processing of tryptamine or tryptamine derivatives?  *
Do you have any other medical issues that might affect your participation in our ceremonies? *
Please state all physical or mental limitations and restrictions of which you are aware:  *
Are there any particular traumas which you are seeking to address and heal from? (birth trauma, childhood trauma, sexual assault, accidents, sudden loss or change, etc).

If you do not feel comfortable sharing here, we can speak over Signal or Telegram, or you can give a simply phrased answer here and we can speak more in detail later.
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Have you worked with plant medicine before? *
If Yes, please describe your experience.
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Please describe, if any, your experience(s) with psychedelic, psychotropic substances, and/or recreational drugs (what kind, how often, etc.)

If you are uncomfortable sharing this information here, we can have a separate conversation on Signal or Telegram to ensure further privacy.
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What are your intentions/personal reasons for participation in this retreat? 
Why are you interested in plant medicine?  
What areas of your life are you looking to address, and why do you think plant medicine will help?
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Do you regularly experience any type of physical, mental or emotional distress or pain?  *
Do you feel safe in your home?
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Do you have an embodied awareness of the current state of your nervous system? *
I have read and accepted this document.
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Full Name
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Date Read and Signed
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KAMBO HEALTH FORM + LIABILITY WAIVER
It is required to fill out and submit our health form and liability waiver before sitting with Kambo. Kambo is not safe for everyone.

* All information disclosed in this form is strictly confidential. It is imperative that you answer in as much detail as possible and be completely honest, as lying or foregoing health information can be dangerous. Safety is our main priority. The ceremony is a judgment-free space and it is for your deepest healing and safety that the facilitator knows your medical history. WaiverForever is HIPAA approved.

**DISCLAIMER: Please note that none of the ceremony offerings on this website constitute any form of medical practice. Kambo is not a 'medicine' as defined by western standards or recognition. I as a practitioner am not a doctor nor any other form of medical practitioners and I do not hold any western medical education or degree.

I, as a facilitator, do not diagnose disease, treat physical or mental health issues, prescribe medications, or claim to 'cure' any disease or sickness, mental, emotional, physical or otherwise.

Kambo is a ritual from the indigenous tribes of the Amazon Rainforest for increasing vitality - it is not a medical treatment.

Participants who are interested in sitting in this ritual are advised to do further research as to the potential benefits and risks of Kambo to determine if this could be an effective and appropriate experience.**

Height *
Weight *
Ethnicity *
How did you first hear about Kambo? *
Have you worked with Kambo before? *
Required

If yes, how many times? Please describe your experience.:

(What was the ceremony process like for you? What came through for you? What did you experience physically, mentally, emotionally? What type of purge did you have, if any?)

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What are your intentions for sitting with Kambo? What is drawing you to this medicine as an avenue for healing?*:

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Are you currently under the care of a physician?

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Primary Care Provider Name, Address, Phone Number (or type n/a)

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Are you currently under the care of a mental health practitioner?

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Do you have any of the conditions listed under the "contraindications" section?*: 

Find a list of all contraindications here:

 https://guidedbyanura.com/kambo

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If Yes, please explain which contraindications in detail, specific to your condition.

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Are you able to complete a 30-minute high intensity cardio workout?

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Do you have any allergies? If yes, please list below in detail.

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Are you currently, or have you ever had, any addiction to alcohol, drugs, food, etc? Please explain in detail.

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Please describe in detail any prior history with anorexia and/or bulimia, if any.

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Please list any medications you are currently taking. (Name, dosage, frequency.)

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Please give a detailed description of your history with prescription and recreational drugs.

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Have you been vaccinated against COVID-19?

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If yes, Please disclose the number of doses, brand and dates which you received the vaccine.*: Ex: One dose of Sinovac, June 2021

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Please list any side effects you experienced after receiving your vaccine, or if you are experiencing long-term COVID symptoms.

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Please explain in detail if there are any known birth traumas.:

(ex: c-section, premature, ICU, etc)

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Please explain in detail any major accidents, severe stressors, physical or emotional traumas or major lifetime events.

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Do you have a history of depression, bipolar disorder, manic behavior, or psychological instability? *:

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If Yes, please explain in detail.

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Please describe all hospitalizations, surgeries or significant medical history the facilitator should know about.

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Do you have any known heart conditions, surgeries or equipment?

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If Yes, please explain in detail.

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Do you currently or have ever had problems with the kidneys, liver or other organs? Please explain in detail.

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Have you been diagnosed with any Auto-Immune disorders? If yes, please describe in detail.

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Do you have high or low blood pressure? If so, are you taking medication?

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It is important for your safety and the safety of your practitioner to be honest and forthright if you have any of the following conditions. Please check all that apply.:

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Is there anything about your physical or mental state the facilitator should know about?

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If Yes, please explain in detail.

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What previous methods or practices of alternative/holistic healing have you tried? *:

Fasting, Reiki, Acupuncture, Yoga, Meditation, etc. Please explain the duration, frequency or regularity of each practice.


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Any other comments/notes for the facilitator:

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I herby acknowledge that I have voluntarily applied to participate in the Soul Harmony plant medicine healing retreat. I understand that by signing this document I accept and assume responsibility for any and all risks, whether or not specifically itemized herein, to include travel to and from activities and facilities. I hereby release, waive, discharge and covenant not to sue the event’s leader, organizers and participants from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted.  To the best of my knowledge, I am in good physical condition and I am not aware of any physical and physiological infirmity, which would place me at risk to participate in any way with the ceremony activities. I am fully aware of the risks and hazards connected with this event. I voluntarily assume all responsibility for any risk of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. In signing this release, I acknowledge and represent that I have read and understand it and sign in voluntarily; I am least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same. I hereby irrevocably release Guided by Anura, Casa Floresta, Forest Path, its employees, associates, board members, property owners, family of the same and any organization that Anura represents or contracts with. They shall be held harmless and blameless in the event of any mishap. I understand that the retreat and recreation activities which are a part of the retreats at Casa Floresta may involve some risk of injury or death from various hazards, both obvious and obscure, including but not limited to, injury by acts of other group participants, falling, being struck by falling objects, jungle fauna and flora, and other risks or occurrences not set forth in this agreement. I am prepared and aware of the possibilities of risks and will not look to any entity or individual nor hold them responsible for my well being or the protection from such risks whether or not those risks are known or unknown by those organizations or individuals.
I am also aware that medical services or facilities may not be readily available or accessible during some or all of the time that I am participating in the retreat. I agree that Yacumama Sanctuary, its principals, guides and agents are not liable for the adequacy or availability of any equipment or supplies that may be provided in conjunction with the retreat, or for the adequacy or availability of any first aid or medical care, or the negligent provision of first aid or medical care by it or by its guides or agents, participants, or by any physician, emergency care facility or any other person.
I agree to disclose in my application all truthful information relating to my medical history, current medications and dosages, vitamins or supplements being taken as well as allergies to medications or environmental substances.  I agree to disclose any changes made in my dosages of medications to the  before the retreat begins.  If I am on an anti-depressant medication or any substance that is contraindicated with the use of plant medicines, I agree to discontinue it’s use no less than three weeks before the retreat begins.
I further agree to respect the person and property of others, and to abide by the rules of theSoul Harmony Retreat. I understand that violation of those rules may lead to my expulsion from the retreat and facility without refund.
BY CLICKING THE INDICATED BOX ON THE APPLICATION FORM, I AGREE THAT I HAVE READ CAREFULLY THIS LIABILITY WAIVER AND FULLY UNDERSTAND AND AGREE WITH THEIR CONTENTS. I AM AWARE THAT THEY CONTAIN RELEASES, EXEMPTIONS AND LIMITATIONS OF LIABILITY, AND ARE PART OF THE CONTRACT BETWEEN MYSELF AND Guided by Anura / Yacumama Sanctuary / Soul Harmony Retreat. *
Required

Health and Liability Agreements

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Please fill date read and completed:

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Please fill in your name: First Name, Last Name, Initials


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Please type your name initials:

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Sign to acknowledge you have read and understand the health+ liability agreements, and have shared all health information honestly.

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