Apply for a Retreat

To join us for a retreat, please fill out this application and we will respond to you as soon as possible.

The information shared in this application will be kept private and confidential.

For your own safety please provide accurate and truthful information.

* required fields

Full Name *

Address *

State and Country *

Home phone

Mobile phone *

Email *

Facebook or other social media profile link *

Occupation *

Gender *

Date of birth *

Emergency contact name *

Emergency contact phone *

Diet *
vegetarianveganmeat, chicken, fishdifferent

Food allergies and restrictions

Why do you want to come to this retreat? *

Do you have any previous experience with shamanic plants, with shamans, or in ayahuasca retreats? When and Where?

How do you handle crises? Explain: *

Do you have any medical or psychological conditions? *
Have you ever been hospitalized? *

Are you currently taking any kind of medication or supplements? *
Do you have a history with substances or addictions? *

Health insurance for travel - company and policy number:

How did you learn about us? *

Any other comments?

Date *