Application form - Magic exists....

Home
About Us
- Meet the Team
Retreats
Plant Diet
Location
Amazon Rainforest Conservation
Contact Us

Amazon Rainforest Conservation
Application form
Ayahuasca Ceremony
Ayahuasca Preparation and Diet
Book a Retreat
Contact Us
Location
Meet the Team
Photo Gallery
Plant Diet
Retreat Overview
Schedule & Prices
Yoga Sessions
Yoga, Meditation, Ayahuasca Retreat in Iquitos, Peru

Thank you for applying to participate in our retreat!

The following questionnaire is to make sure you will have a safe and enjoyable experience. We accept a maximum of 5 participants per retreat, and we will be delighted to have you with us. We are looking forward to hear from you and get to know you!

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Gender *

Male
Female
Prefer not to say

Email *

Mobile number with country code *

Date of birth *

Arrival date at the retreat (please, remember retreats starts on Mondays, so this date must coincide with any Monday of the year) *

Emergency contact information *

Have you had any injuries or accidents? *

Have you participated in an Ayahuasca Ceremony in the past? *

Do you follow a specific diet? *

recreational

Do you have any of the following: *

Allergies
Asthma
Claustrophobia
Depression
Diabetes
Epilepsy
Heart disease
High blood pressure
Blood disorder
Bipolar disorder / schizophrenia

Beside of the above, do you take any medication or tablets? *

Did/do you consume any type of drug? *

Do you drink alcohol? *

If yes, please mention an average quantity and frequency

Terms and conditions: By submitting this form, I certify that the information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. I certify that by the time of the retreat I will not have consumed any recreational drugs, nor prescription for anxiety/depression/sleep or any other undisclosed medicines. I understand that failure to do this implies to put my health at serious risk. *

I agree

Scroll to Top

× Contact us