Vision Quest

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* These fields are required

1 Welcome

2 Price

3 Optional Items

4 Participant Info

Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Country *
Gender *
Birth Date *
Age *
Dietary Restrictions *	Do you have any dietary restrictions or allergies that we need to know about.
Terms and Conditions *	I accept the terms and conditions.I accept full responsibility for participating in a retreat and in the ceremonies at Hayulima Sanctuary. I have answered all the medical questions on this form completely and honestly. I understand and agree that I can be excluded from participation in a retreat or ceremony at the discretion of the facilitator or Shaman. I agree to respect all individuals at all times. I understand that I can opt out of any ceremony before a ceremony starts but cannot leave a ceremony until it is over. I understand that these sacred medicines are not a substitute for medical, psychiatric or psychotherapeutic treatments but may complement a therapeutic process and facilitate personal development.
Emergency Contact Info *
Medical Issues *	Enter "none" if you have no issues
How did you hear about us? *

5 Health & Medical Questions

Please answer all these questions completely and honestly. We want to keep you safe during your stay.

Do you have any medical issues that we should know about? (asthma, diabetes, epilepsy etc) *
Have you had or do you currently have any mental illness that we should know about? (Bipolar, schizophrenia, dementia)? *
Do you have any heart conditions? Please explain *
Please list any antidepressants or antipsychotic medications that you currently take? *	You must be off these medications completely for at least a full two weeks before the retreat.
Are you taking any other medications? *	There are medications that should not be taken with the medicine so it is good for us to know.
Have you had any surgical procedures or operations in the last year? Please explain *
First Emergency Contact, First Name and Last Name * *
First Emergency Contact - Relation to you *
First Emergency Contact - Phone Number *
First Emergency Contact - Email Address *
Second Emergency Contact, First Name and Last Name *
Second Emergency Contact - Relation to you *	Relation to you
Second Emergency Contact - Phone Number *
Second Emergency Contact - Email Address *
Please specify the dates/month for your vision quest *
Passport or ID number *
Vision Quest *
Do you grant us permission to use photos of you taken during your stay for our social media and marketing purposes? *	Yes No
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

6 Security Check

7 Payment