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 *

Date of birth *

Emergency contact name and phone *

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? *

When was the last time you took a medicine or supplement and for what? *

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

Have you ever been hospitalized? Why and when? *

Health insurance for travel - company and policy number:

How did you learn about us? *

Any other comments?

Date *

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Upcoming Retreats

  • Mar  9 — Mar 17
  • Apr  1 — Apr 11
  • May  22 — May 30
  • Jul  3 — Jul 13
  • Aug  15 — Aug 23

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