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.
Your Identity
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 answer
Your Date of Birth *
Please enter your date of birth as shown on your passport.
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Biological Gender *
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.
Your Nationality *
What is the nation of issue of your passport?
Your answer
Passport Number *
What is the number of your passport?
Your answer
Expiry date of your passport *
On what date does your passport expire?
MM
/
DD
/
YYYY
Your Normal Residential Address: *
Please write your full residential address, including country and zip/postal code.
Your answer
What is your primary email address? *
We will use this address for confirmation and relevant information posts only. We do not share data.
Your answer
Your primary cellular number: *
Please use the format +51 983555555 with country code and number that you may receive text alerts on.
Your answer
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
All other regular contact details you can think of:
Other email addresses, phone numbers, Facebook identity, etc. One detail per line, please.
Your answer
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.
Your answer
Medical History
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: *
Required
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.
Your answer
Please include any details that are appropriate to your above responses.
Your answer
Medication and Drug History
This is for your potential survival. We need to know if you
Have you ever used, irregularly or habitually: *
Required
Please include any details that are appropriate to your above responses, including any long term effects identified.
Your answer
Psychedelic or Hallucinogenic Experience
Do you have any personal experience with any of the following?
Please detail any history you have with psychedelic use, including your sensitivity, your positive and/or adverse responses, and general nature of your experiences.
Your answer
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)
Required
Personal Declaration
*
Required
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