Checkout Final - Sanken Nete

Retreat Registration

Full Name:*

Phone number:*

Email Address Participant 1:*

Full Name Participant 2:* (If applicable)

Email Address Participant 2:* (If applicable)

If you have booked a double room would you like a king bed or two twin beds? ( It is important to note that only some of our double rooms have an option for twin beds and you can see this in the room description.)

Twin beds King bed N/A

Gender

Are you taking medications* (All information disclosed will be handled confidentially and will be kept in the strictest confidence.)

Yes No

If you marked yes in the last question. Which ones? If not write N/A*

Have you in the past taken any recreational drugs, such as marijuana, cocaine, heroin, etc?*

Yes No

If so, when and how frequently?, if no write N/A*

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

Yes No

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

Do you have any psychological conditions that we should know about, such as bipolar disorder, history of depression, PTSD, history of trauma, suicidal tendencies or thoughts, etc?*

Yes No

If yes, please specify. 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 worked with Aya-huasca or will this be the first time? Have you ever worked with any other hallucinogenic compounds, such as L-SD, mush-rooms, San-pedro, Pey-ote, etc?*

Yes No

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

For our sisters, please fill in the following information:* (Your age? Is your cycle regular or irregular? Dates (start & end) of last moon cycle? Date of expected next moon cycle start? Number of days you normally bleed? If you entered menopause how long ago? By filling in this field I acknowledge that I won't be able to join the Ayahuasca ceremonies if I am on my menstruation cycle.)

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

Are you willing to take part in this retreat with Ayahuasca ceremonies and all other group activities, absolving us of any responsibility and liability? As well, do you confirm that you have read the safety diet and you are not taking any medications or have physical / 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. The Nature Within reserves the right to cancel a program at any time. If The Nature Within cancels a program, you will receive a full refund. A refund, minus a processing fee ($200 plus 3% of the cost of your room), 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.' We highly recommend that you purchase travel insurance, which insures you against unforeseen sickness, injury, job loss, inclement weather, and more.)

Yes No