Plant Sacrament Ceremony Application
This form is for the exclusive use of guests and clients of Dapsin SAC, and associated trading entities, officers and representatives, including 'Shaman's Hearth', 'SacredTeachers.org', 'Scenic and Sacred South America', and 'ScenicSacred.com'.
Contribution (USD$90 or S/.300 per person)
Please select your desired payment option. If using Paypal or bank transfer, please use the ceremony date and your family name (e.g. 2017may25Jones) as the payment detail.
Cash on the day (please bring correct money where possible)
Bank transfer (details will be forwarded. (Incoming transfer fees are extra, and vary depending on transmitting nation.)
This information is required, and must match your passport
Your Full Name
Please write your full name exactly as it appears on your passport.
Your Date of Birth
Please enter your date of birth as shown on your passport.
As identified on your passport.
For women, are you pregnant, or is there a chance of you being pregnant?
Pregnancy does not preclude a woman from drinking plant sacraments, but the decision must be an informed one, and belongs to the pregnant woman, and nobody else.
Yes, I am currently pregnant.
I may possibly be pregnant.
To the best of my knowledge, I am not pregnant.
What is the nation of issue of your passport?
What is the number of your passport?
Expiry date of your passport
On what date does your passport expire?
Your Normal Residential Address:
Please write your full residential address, including country and zip/postal code.
What is your primary email address?
We will use this address for confirmation and relevant information posts only. We do not share data.
Your primary cellular number:
Please use the format +51 983555555 with country code and number that you may receive text alerts on.
If we have a WhatsApp contact for you, we will use that in first preference to text (SMS) messaging. If it is not this number, please indicate with the next question which WhatsApp
This is my WhatsApp contact number.
All other regular contact details you can think of:
Other email addresses, phone numbers, Facebook identity, etc. One detail per line, please.
Emergency Contact Details
Please enter completely the name, relation, address, and contact methods for whom we should contact for you in an emergency. You may add more than one contact in this same section.
These questions are for your safety, and ours. If you received therapy or medications in treatment, we need to know about it. Please answer honestly.
Have you experienced, been diagnosed with, or have:
HIV/AIDS, hepatitis of any type, or any other blood or saliva transmissible condition
Allergies requiring medication or emergency treatment
Cancer or other condition treated with chemo or radiation therapy
Cardio-pulmonary event requiring medication or treatment
Cerebro-vascular event, including stroke, TIA, aneurysm etc.
General anaesthesia within 18 months
Epilepsy, non-infection based seizures
Diabetes, blood sugar level issues
Blood clotting disorders, thrombosis, or other vascular occlusion disorders or conditions
Digestive tract integrity issues (GI bleeding, ulcers, hypersensitivity to known agents)
I have not experienced or been diagnosed with any of the above, or similar conditions.
Your General Health
Please detail a clear and real picture of your overall health and fitness levels, including any recent investigations or checkups that showed things being good, as well as anything of concern. We are particularly interested in your cardio-pulmonary (heart and lung), circulatory (blood), and digestive (gut) health. Your physical fitness and overall exertion tolerance, flexibility etc. all rate in how we work with you in ceremony. Please also detail here ANY FOOD SENSITIVITIES leading to requiring of medication or significant changes to bowel or other functions.
Please include any details that are appropriate to your above responses.
Medication and Drug History
This is for your potential survival. We need to know if you
Have you ever used, irregularly or habitually:
Methamphetamine (including crystal meth)
Cocaine, Bath Salts, other types of speed or stimulants
EPO, or any other RBC influencing factors
Anabolic steroids, rhGH, or other growth regulating agents
Lithium or other anti-psychotic, or anti-seizure agents
Any other agents known or suspected to be linked to heart, lung, blood vessel or digestive issues.
SSRI or other anti-depressants, mood modifiers, adhd type medications or similar
I have not used any of the above, or similar agents.
Please include any details that are appropriate to your above responses, including any long term effects identified.
Psychedelic or Hallucinogenic Experience
Do you have any personal experience with any of the following?
Huachuma/Wachuma/San Pedro or Peyote
LSD, MDMA, or similar
Other plant medicines or sacraments
Any other psychedelic or hallucinogenic substances not listed above
I have no personal experience with any psychedelics, hallucinogens, or similar substances.
Please detail any history you have with psychedelic use, including your sensitivity, your positive and/or adverse responses, and general nature of your experiences.
Personal and Psychological History
These questions are for your safety, and ours; please answer honestly and completely.
Have you ever received medication, treatment or diagnosis for:
(Including the associated spectrum disorders)
Anxiety or panic attacks, debilitating sensory overload leading to shutdown or panic, or similar
PTSD or similar
Type 1 or 2 BiPolar Disorder, Manic disorders or conditions (hypermanic or hypomanic)
Borderline Personality Disorder, Schizophrenia, Multiple Personality Disorder
Psychotic or other mood-personality-behavioural breaks
Delusional breaks, incl. visual, auditory or other sensory hallucinations
I have not received medication, treatment or diagnosis of any of the above, or similar conditions
I, the person described and identified above, do faithfully declare that all of my responses on this form are complete and correct to the best of my ability and without deliberate omission.
I understand and consent to life or safety preserving measures as required during any activity or event to which this form is applicable.
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