One-Week Advanced Ayahuasca Retreat | Cusco, Peru | January 30

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Have you ever been diagnosed with any physical illnesses? Please explain in detail. *	Enter "none" if you have no issues
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Has anyone in your immediate family ever been diagnosed with a mental health condition? *
Has anyone in your immediate family ever been diagnosed with any severe heart or brain conditions? *
Please list any medications you have taken in the past and how long you've been off of them. *
Please list any medications you are currently taking including their name, frequency, and dosage. *
Please share your history with any drug and alcohol usage and/or addiction. *
Please share any experience you've had with psychedelics or plant medicines. *
Please share a bit with us about your intentions for coming and working with plant medicine. *
Have you ever been diagnosed with a mental health condition? (This will not disqualify you from being eligible for plant medicine, we just would like to know). *
Have you ever had a seizure? *
I understand that I will pay my remaining balance in cash upon arrival to the retreat. *	Yes No
Have you ever been diagnosed with any mental illnesses? Please explain in detail. *
Terms and Conditions *	I have read and accept the terms and conditions of Anam Cara's payment and booking policy. All retreat deposits, once paid, are nonrefundable in order to reserve your space. Upon receiving your application, we will closely review your medical history and follow up via email to let you know you have been approved. Once approved, you can move forward with travel plans. If upon reviewing your medical application we find that working with Ayahuasca is unsafe or not a good fit for you due to safety or health risks, we will refund your deposit and kindly deny your application. For any reasons other than medical safety risk at the time of application, retreat deposits are nonrefundable and nontransferable. After paying your $1400 retreat deposit via credit card, you will pay your remaining balance in cash USD on day 1 of your retreat. If for any reason you do not show up for the retreat, your credit card on file will be charged the remaining retreat balance. If you need to make changes to your reservation, we may be able to transfer your deposit to another retreat date if we have more than 30 days notice. Cancelations made 30 days within the retreat date window are not refundable or transferable.
A deposit of $2000 USD is required to reserve your space on this retreat. At the time of registration please pay your deposit or your application will not be processed. Payment Options- No Fee, deposit can be sent via Zelle. With a fee, payment can be sent via bank wire transfer or stripe link to pay via credit/debit card. You will be redirected to the the deposit payment page after submitting this form. *
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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