Private Ceremonies - Con Smania Costa Rica - Transformational Retreat Center

Please take the time to complete this form as soon as possible so we can be of best service to you.

1About You

2Mental And Physical Health

3Releases

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Name(Required)

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Mental and Physical Health

Some of these questions are really personal, this information is confidential and helps us to provide a safe environment for you, please be as detailed as you feel comfortable. There are certain contraindications for working with entheogens, it is of paramount importance to be truthful and clear in your responses.

Age(Required)

Height(Required)

Weight(Required)

Gender(Required)

Male

Female

Non-binary

Do you have a period/ moon?(Required)

Yes

No, I am post-menopausal

No, it is surpressed

What is the date of your last moon?(Required)

Have you ever worked with Bufo? Have you ever worked with any other hallucinogenic compounds, such as LSD, mushrooms, San Pedro, Peyote, etc? If yes, please describe your experience(s)(Required)

Have you experienced the following conditions, chronic illnesses, surgeries:(Required)

Cardiovascular

condition (or have family history)

Stroke

Low Blood Pressure

Blood Clots

Brain Aneurysm

Brain Hemorrhage

Serious Mental

Health Conditions

Chemotherapy

(Provide Date Last Taken Below)

Immunosuppressant Medication

Organ Transplant

Herxheimer Reaction

Hyponatremia

Pregnant or

Currently

Breastfeeding

Vagus Nerve Reflex

Hypoglycemia

Bulimia or Anorexia

Mold Poisoning

None of the above

Please expand on any physical disabilities, surgeries, allergies, conditions, past injuries or any limitations we need to know about.(Required)

What medications are you taking or will you take during the week? Please list any precautions and side effects and length of time you have been taking them.(Required)

Have you in the past taken any recreational drugs, such as marijuana, cocaine, heroin, etc? If so, how frequently? When was your last use?(Required)

Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological conditions?(Required)

You can respond here at the level you are comfortable. Remember, "I choose not to share this information" is a perfectly valid response and we will speak to you directly.

Do you have a history of sexual or physical abuse? Do you have a history of substance abuse? Do you have a history of suicidal tendencies or a suicide attempt?(Required)

You can respond here at the level you are comfortable. Remember, "I choose not to share this information" is a perfectly valid response!

Is there any other information you would like to inform us of?(Required)

If I should warrant immediate medical attention while participating in a ceremony, I hereby grant permission to the medical personnel contacted to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted.(Required)

Yes, permission granted

No, authorization can only be granted by my emergency contact. I understand that in the case of being unable to reach my emergency contact, Good Samaritan procedures will be put into effect and care will be given to the best of the person's ability.

If I should warrant immediate medical attention while participating in a ceremony, I hereby grant permission to the medical personnel in attendance or contacted to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.(Required)

Yes, permission granted

If I should warrant immediate medical attention while participating in a ceremony, I hereby grant permission to the physician selected by the facilitators to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me.(Required)

Yes, permission granted

I agree to adhere to the decision by the facilitators, regarding the suitability of my participation(Required)

Yes, I agree

No, I do not agree and recognize this may be grounds for removal from the retreat.

All statements I have made in this document are accurate and correct to the best of my knowledge at the time of submission. I agree to update the facilitators with any additional information pertinent to my attendance at the retreat.(Required)

Yes, all is correct.

No, I do not agree and recognize this may be grounds for removal from the retreat.

Terms and Releases

As an attendee at a private ceremony, you are in a relationship with your facilitators.

Are you willing to take part in this event with plant medicine ceremonies, absolving the facilitators of any responsibility and liability?(Required)

Yes

Release of Liability and Assumption of All Risks(Required)

PLEASE READ CAREFULLY: THIS IS A LEGALLY ENFORCEABLE WAIVER OF RIGHTS

ASSUMPTION OF RISKS

I acknowledge that I have voluntarily applied to participate in the private ceremony. I am voluntarily participating with knowledge that this involves numerous risks and dangers including, but not limited to, a risk of illness, injury or death, which may be caused by: forces of nature, injuries inflicted by animals, insects, reptiles or plants; accident or illness without access to means of rapid evacuation or the availability of medical supplies; the lack of adequacy of medical attention once provided, and negligence on the part of Jill Sessa, their affiliated organizations and their shareholders, employees, teachers, facilitators and contractors, volunteers or other agencies. I acknowledge that the enjoyment and excitement of private ceremony is derived in part from the inherent risks incurred beyond the accepted safety of life at home or work, and that these inherent risks and the corresponding enjoyment and excitement contribute to the reason for my voluntary participation in this ceremony.

I am aware that this ceremony involves the use of plants, plant-based mixtures, and traditionally-used organic compounds and entheogens, which may include DMT, which is traditionally used for healing and vision-questing. Hereafter, these will be referred to as “entheogens”. I am aware that this ceremony involves practices such as meditation, yoga, breathwork, and dynamic movement, as well as other activities.

I acknowledge that taking these psychoactive entheogens may involve, as part of a guided introspection process, some emotional and physical reactions, and agree to take part and abide by the terms and conditions in this document, and as suggested by the facilitators of the ceremony.

I agree to make any and all confidential disclosures at the time of, or prior to booking any ceremony(ies) regarding all medical conditions and/or use of any medication and other substances. I agree to notify the Facilitators of any change in medical circumstances prior to ceremony.

Facilitators recommend that, prior to ceremony, the Participant seeks and obtains health or medical advice regarding the potential effects of these substances and practices in combination with any medication they are taking, or with any psychiatric condition they may have.

I avow I am in a physical and mental condition appropriate to the activities described in these ceremonies and agree to participate at my own risk and responsibility. I am responsible for taking accurate and timely health precautions and seeking professional medical advice prior to ceremony.

I am voluntarily taking any, all, or none of the entheogens being offered. I take full responsibility for my actions and conducting appropriate research into the possible effects of the entheogens.

I acknowledge that accurate reporting of the required information is necessary to help ensure I have a safe and beneficial experience and that failure to provide accurate information in this Agreement may compromise their experience and health.

To the best of my knowledge, I am in good physical condition and unaware of any physical or psychological infirmity that would place me at risk to participate in any way.

In the event of a medical emergency, I agree to seek emergency medical care and give permission to initiate contact with their emergency contacts and/or nearest medical providers according to the selections above.

As the Participant, I am informed that these ceremonies are mainly an educational process and part of my personal quest to take better care of myself. I am aware that I am responsible for my own physical, emotional, mental, and spiritual wellbeing, and I hold myself accountable for every decision I make.

I am not being treated for any illness or deformities as part of these ceremony(ies). I acknowledge these ceremonies have elements of shamanic wisdom, ancient traditional vision quests, and modern psychological tools used for self-discovery.

I agree to take part in these traditional, sacred medicine ceremonies and other self-inquiry techniques with the facilitators and associates. Facilitators and their associates will do their best to ensure the participant’s safety and comfort within the area subject to the limitations herein. I agree to exercise caution and consideration for myself and for others during these ceremonies and indemnifies the facilitators and their associates against claims for injury or loss.

I voluntarily take full responsibility for any risk of loss, property damage, or personal injury or any loss or damage to property owned that happens as a result of being engaged in the ceremony activities, whether caused by the negligence of release, or otherwise.

I acknowledge that the ceremony(ies) are not undertaken within the scope of any professional license, rather held by experienced, qualified facilitators. Participant waives any right to a jury trial.

In agreeing to this release, I acknowledge and represent I have read, understood, and submitted this form voluntarily; I am a legal adult of at least twenty-one years of age or older. This Agreement applies to all present and future work with the facilitators.

I acknowledge no oral representations, statements, or inducements have been made by the facilitators and associates to take part in these ceremony(ies).

I agree not to publish, teach, or in any way try to impart these ceremonial techniques and knowledge to the general public. I have made the requested confidential disclosures to the facilitators and have provided accurate information regarding my needs and conditions. I acknowledge the information will be kept in strict confidence.

RELEASE

AS LAWFUL CONSIDERATION for being permitted to participate in private ceremony activities, I hereby agree that I, my heirs, legal representatives or any member of my family will not make a claim against or sue Jill Sessa, or any of their affiliated agents, shareholders, employees, teachers, facilitators and contractors, or volunteers, for bodily injury, death, emotional trauma or property damage resulting from my participation in the tour or expedition.

I therefore release and discharge Jill Sessa, and their agents, shareholders, employees, teachers, facilitators and contractors, and volunteers from and against any and all liability arising from my participation in the private ceremony even though that liability may arise out of negligence or carelessness on the part of Jill Sessa, or their affiliate agents, shareholders, employees, teachers, facilitators and contractors, or volunteers.

If any portion of this agreement is unenforceable, the remaining portions shall remain in full force and effect. Under no circumstances shall Jill Sessa be liable to any participant. I waive any charge-back rights. All applications are subject to acceptance by Jill Sessa. Upon acceptance of my application, this agreement shall be deemed to have been entered into at Green Cove Springs, Florida and shall be construed according to the laws of the State of Florida. In the unlikely event a legal dispute should arise involving any subject matter whatsoever, I agree that the exclusive venue for any legal action shall be Green Cove Springs, Florida, USA.

KNOWING AND VOLUNTARY EXECUTION

I have carefully read and fully understand the contents of this agreement. I am aware that this is a release of liability and a legally binding and enforceable contract between myself and Jill Sessa and I sign it of my own free will.

I hereby accept any and all risks of illness, injury, emotional trauma, or death and verify this statement by checking this box

Signature of Agreement to the Release of Liability and Assumption of All Risks(Required)