Wondering if Kambo : Bufo : or plant medicines are for you? Take a minute to fill out our application form Kambo / Bufo/Plant Medicine ApplicationThese ceremonies are primarily a spiritual undertaking and although personal growth can occur the experience should not be seen as a substitute for medical care. Participation in these ceremonies can involve dramatic experiences accompanied by strong emotional and physical release. This is not appropriate for those with underlying medical conditions or those who are using certain medications. If you have any doubts or concerns about whether you should participate, consult with the organizer(s) before attending. Please answer the following questions honestly in order evaluate your ability to attend the event. Failure to disclose any medical condition or medication can result in hazardous outcomes including death. The organizer(s) accept no liability for any conditions arising from false or incomplete information provided by event applicants.Please enable JavaScript in your browser to complete this form.Name *FirstLastCurrent Age *Email Address *Phone Number *Emergency Contact *FirstLastPhone Number *Would you like to be added to our mailing list to keep up to date with offerings? *YesNoHow did you here about us? *InstagramFacebookTikTokFriendOtherPlease share who referred you or explain "other"Which offering are you interested in participating in? *Private Kambo session(s)Private Bufo session(s)January 2024 4 week plant medicine integration groupPrivate Forest Medicine SessionPrivate Group Kambo Session(s)Private Group Bufo Session(s)If other please elaborate on what you would like to participate in. Please take a moment to share what are your intention(s) are for wanting to participate. The more detail you provide the better we can support you *On a scale of 1-5 with 5 being the highest indicate your level of : Stress Selected Value: 0 On a scale of 1-5 with 5 being the highest indicate your level of : Anxiety Selected Value: 5 On a scale of 1-5 with 5 being the highest indicate your level of : Support from family/friends Selected Value: 0 Have you had any issues with your heart, including any high or low blood pressure? *YesNoIf yes please explain in detailHave you experienced any seizures, have a seizure condition such as epilepsy? *YesNoIf yes please explain in detail Do you have a past history of, or currently live with, any of the followingCardiovascular Disease, Including Heart AttacksHigh or Low Blood PressureMental Illness (Anxiety, Depression, Bipolar, Schizophrenia, etc.)Recent SurgeryPast or Recent Physical Injuries (Fractures or Dislocations)Glaucoma, Retinal Detachment or any Eye DisordersRecent or Current Infectious Diseases or Communicable IllnessesSeizures or EpilepsyAsthma or Other Respiratory ConditionsDiabetesCancerDigestive IssuesChronic IllnessAddictionOrgan or Tissues TransplantPlease provide further information for all health conditions indicated with a check mark.For female participants:Are you pregnant or do you suspect you might be pregnant?Are you breastfeeding?Might you be on your moon cycle at the time of ceremony?Please provide any additional details you may feel are of relevance.Please list any recreational or ceremonial substances you may have consumed in the last 2 months (including alcohol, tobacco, marijuana, LSD, psilocybin, etc.). Include the frequency of use. *Please list any pharmaceutical medications you are currently on. Include dosage and frequency of use. It is important that you share the frequency of use and the dosage. *Please list any supplements you are currently on. *Do you go to therapy or are you in a support group? Please provide any pertinent details. *Do you have any health or medical conditions that have not been shared above? *Have you received an mRNA vaccine? If yes, please provide the following information below: i) Date of Vaccine 1 ii) List any side effects experienced iii) Date of Vaccine 2 iv) List any side effects experienced *Do you have any fears or phobias? *If you have experience working with Kambo and/or Bufo then please provide the approximate month/year of your last ceremony and name of your practitioner(s) *Consent and Liability Waiver I acknowledge that participation in the sacred ceremony may involve discomfort and unexpected physical, mental or emotional upset. In submitting this release document, I agree to waive all rights to seek or receive compensation in case of injury, loss or damage. I choose to attend this work as a result of my research and interest in ceremonies. I understand that my participation in this ceremony is entirely voluntary and I agree to remain at the ceremony to its completion. I accept that the ceremony practitioners and helpers make no claim or promise about the curing of illness of any kind, or about the nature of any spiritual experience which I understand is entirely personal. I understand that my participation in the ceremony may be physically, mentally, emotionally or spiritually demanding. I understand that I may experience dizziness, nausea or other physical upset including vomiting and diarrhea. I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation and any and all possible manifestations of physical, emotional and mental changes. I acknowledge that I am aware of the risks and potential benefits of my participation and I freely choose to enter this process, accepting full responsibility for whatever may occur whether anticipated or unanticipated. I acknowledge that I will make alternate arrangements for transportation in the event that I may be physically or mentally exhausted and/or disoriented after the ceremony. I am informed of the nature of the ceremony, the needed preparation and the rules of the ceremonies. I commit myself to stay in the circle until the end of the ceremony and to respect the directives given by the organizers, helpers and facilitators(s) of the ceremony. I hereby knowingly and voluntarily assume the full risks of any physical or moral injury, damage or losses, either to myself or caused to others by me during the Ceremony. I hereby waive the liability of and agree to hold harmless: the practitioner(s), all the helpers, associates, employees, agents, staff, family successors, volunteers and other participants. I further agree to defend and indemnify them from any claims, suits and demands. This agreement is binding upon myself, my spouse, parents, family, heirs, executors, administrators, agents and assigns. *I hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly and have not withheld any information. I have read, understood and consent to the waiver voluntarily.Submit