Apply for Program

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

For your own safety please provide accurate and truthful information. 

To join us for a retreat through the Ayahuasca Awareness Program, please fill out this application.

* required fields

Full Name *

Address *

Country of Residence *

Country of Citizenship *

Home phone

Mobile phone *

Email *

Facebook or other social media profile *

Occupation *

Gender *
MaleFemale

Date of birth *

Emergency contact name and phone *

Diet *
vegetarianveganmeat, chicken, fishdifferent

Food allergies and restrictions

Why do you want to come to this retreat? *

Ayahuasca Awareness Program


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

How do you handle crises? Explain: *

Describe personal and/or family history of depression, psychological disorders or imbalances, suicidal thoughts. *

Are you currently taking any kind of medication and/or supplements? *

Do you or a family member have a history with substances or addictions? * Explain:

Have you ever been hospitalized? *

Health insurance for travel - company and policy number:

How did you learn about us? *

Any other comments?

Date *