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Please fill out this form if you are joining us or are considering joining us on one of our upcoming retreats. This form does not secure your space and must be filled out prior to you joining us. In order to secure your space you will need to make the specified deposit.

Deposit for Colombia Retreats: $500.00 USD

Deposit for Mexico Retreats: 50% of total cost of Retreat

First Name

Last Name

Email

Phone Number

Home Address

Gender

Date of Birth

Are you taking any medications?

Yes

No

If you marked yes in the last question, what medications are you taking? What for? and for how long? If not write N/A

Are you currently or have you ever taken any alcohol or recreational drugs, such as cocaine, marijuana, heroin, ketamine, etc?

Yes

No

If yes, when and how frequently? If not write N/A

Do you have any physical conditions that we should know about such as heart conditions, chest pains, high/low blood pressure, etc?

Yes

No

If yes, please specify. If no write N/A

How would you describe your current state of health?

Have you ever undergone major surgery? ( requiring general anesthetic )?

Yes

No

If so, please provide details of the surgery including the aliment, date of operation and any limitations that you are now bound by, etc. If no write N/A

Do you have any psychological conditions that we should know about, such as bipolar disorder, history of depression, PTSD, anxiety, panic attacks, history of trauma, suicidal tendencies or thoughts, self-harm, etc?

Yes

No

If yes, please specify, remember this information is important to us to insure your safety. Please be as honest as possible. The information is CONFIDENTIAL. If no, write N/A

Do you have any special needs we should know about, including allergies or dietary requirements of a medical nature?

Yes

No

If yes, please specify. If no write N/A

Have you ever participated in an Ayahuasca ceremony or worked with any other hallucinogenic compounds, such a LSD, mushrooms, etc.?

Yes

No

If yes, please provide details including dates, location and summary of the experience. If no, write N/A

What is your intention for sitting in these Ayahuasca ceremonies with us?

Is there any other information you would like to inform us of?

How did you hear about us or who referred you to us?

Are you willing to take part in this retreat with Ayahuasca ceremonies, other plant medicines and all other group activities, absolving us of any responsibility and liability?

Yes

No

As well, do you confirm you have you read the pre-ceremony diet preparations that you can find under NEED TO KNOW on our website and you are not taking any medications or have physical or psychological conditions that are contraindicated?

Yes

No

Liability Release*

I acknowledge that I have read the cancellation policy and agree to the terms and conditions. Inner Rising Retreats reserves the right to cancel a program at any time. If Inner Rising Retreats canceles a program, you will receive a full refund. A refund, minus a $200 processing fee, will be offered for cancellations made on or before the close of business, 45 days before each program. No refund or credit will be offered for cancellations made with less than 45 days notice; if you do not show up; or if you leave a program early.

I am voluntarily participating in the Ayahuasca ceremonies and I am participating in the activity entirely at my own risk. I am aware of the risks associated with traveling to and from as well as participating in this activity. Nonetheless, I assume all related risks, both known and unknown to me, of my participation in this activity , including travel to, from and during this activity.

We highly recommend that you purchase travel insurance, which insures you against unforeseen sickness, injury, job loss, inclement weather, and more.

Yes

No

Date

Your Signature

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