Name

First Name

Last Name

HOME PHONE NUMBER

Country

(###)

###

####

MOBILE NUMBER

Country

(###)

###

####

GENDER

DATE OF BIRTH

YYYY/MM/DD

ADDRESS

CITY

COUNTRY

STATE/PROVINCE

ZIP/POSTAL CODE

NAME AS IT APPEARS ON PASSPORT

PASSPORT NUMBER (INCLUDING LETTERS)

PASSPORT COUNTRY OF ORIGIN

PASSPORT EXPIRATION DATE

YYYY

EMERGENCY CONTACT INFORMATION

HAVE YOU EVER EXPERIENCED AYAHUASCA?

If yes, what setting?

Do you suffer from heart problems, respiratory or any other notable physical ailment?

If yes, please explain

If you suffer from schizophrenia or bipolar disorder please contact us for a consultation prior to completing your booking, you require additional medical screening.

Do you experience drug or alcohol overuse/addiction?

If yes, please explain, if desired:

Are you taking any prescription medications, including anti-depressant or SSRIs? Are you taking any herbal supplements?

If yes, please list all

What are your food preferences

If other, please explain

Have you experienced any other psychedelic substances? Please explain.

Is there anything else you want us to know?

DEPOSIT POLICY

* PLEASE NOTE THAT 50% DEPOSIT IS DUE UPON BOOKING. REMAINDER OF BALANCE IS DUE BEFORE OR UPON ARRIVAL IN CASH. DEPOSIT IS NON-REFUNDABLE.

YES, I AGREE

PLEASE CHECK HERE IF YOU ATTEST THAT ALL INFORMATION IS ACCURATE AND YOU ACCEPT FULL LEGAL AND PERSONAL LIABILITY FOR JOINING THIS RETREAT, PROTECTING RYAN JOSEPH AND TEAM MEMBERS FROM ALL LEGAL LIABILITY.

YES, I AGREE TO THE TERMS

***PLEASE DO NOT BOOK YOUR FLIGHTS UNTIL SPEAKING WITH RYAN JOSEPH OR TEAM MEMBERS TO CONFIRM TRAVEL DATES***

YES, I AGREE