Ayahuasca Retreat Application
Retreat Dates you wish to attend:
Emergency Contact ~
Name and Phone Number:
Please inform us of any medical conditions you have had in the past or are presently dealing with. Please list any serious injuries or medical surgeries.
Please list any medications, natural supplements, or vitamins you are currently taking.
Please list any allergies to medications, foods or environmental substances you have.
Have you previously participated in any Ayahuasca Ceremonies? Please give any details and outcomes relating to your experience.
Please write a paragraph on what you would like to accomplish by particpating in Ayahuasca ceremonies. What are your intentions? For example, what fears do you want to overcome? What is most important for you to change about your life? Breaking addictions, release of past trauma, cleansing emotional and energetic centers? Seeking spiritual truth and life purpose, exploring realms for learning and healing? Feel free to write as much as you would like.
Once accepted to the Tierra Vida Retreat we will require your flight itinerary information.
***Tierra Vida is not a Medical facility nor are the staff medically trained professionals. In the event of a serious injury or physical illness the guest will be escorted to a medical facility in Pucallpa. Tierra Vida is not liable for any injury that may occur to any guest during the retreat stay.
***If a guest decides to leave the Tierra Vida Retreat Center prematurely for any given reason, the case will be evaluated and we may reserve the right to decline reimbursement
of any monies.
PLEASE EMAIL US FOR AN APPLICATION:
Please add any further comments or questions.
Conditions and Agreements
Please answer each question in the Application form. Please read the Conditions and Agreements. Make sure to click the "Submit" button at bottom of page.
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