Amanita Muscaria Retreat Registration

First Name *

Last Name *

Phone Number - What'sApp

Email *

Select retreat

By ticking the box you confirm that you are 18 years old or more *

Please confirm that you are 18 years old or more

IMPORTANT NOTE: If you have any health conditions or take any medications please email us at info@greenheartretreats.org to discuss your suitability for participating in sacred plants and/or Kambo ceremonies before you make a booking and submit payment. Medications can not be taken during the retreat time and most have to be stopped with doctor's permission one month before the retreat. Some health conditions make it very unsafe to participate in sacred plants and/or Kambo ceremonies. *

Please check the box to indicate that you have read and understood the above information.

Address *

Address 2

City *

State/Prov. *

Zip/Postal *

Country *

Passport Number *

Note: If the retreat is happening in your own country, please use your personnummer

Country that issued Passport (ID in Case it is your own country) *

Birth Date yyyy-mm-dd *

Height *

Weight *

Gender *

Marital Status *

Profession *

Emergency Contact *

Relationship to Emergency Contact *

Emergency Phone Number *

Emergency Email *

What would you like to focus on - Spirituality

What would you like to focus on - Mental Health

What would you like to focus on - Physical Health

What would you like to focus on - Health and Well-Being

Other areas you want to focus on

Medical History Information - Physical Health

Physical Health Details & Medications *

Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.

Recent Injuries or Active Disabilities

Medical History Information - Heart Health

Heart Health Details & Medications *

Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.

Medical History Information - Mental Health

Mental Health Details & Medications *

Please provide details if you check any condition. Include diagnosis history, any past and current medications including dosage and time on meds. Enter "none" if none of the above have been checked.

Please list any other medications you are currently taking including the dosage and time on medications. *

Enter "none" if you aren't currently taking any medications.

Please list any other medications you have taken in the past. Include when you took them and how long you were on them. *

Enter "none" if you haven't taken any medications in the past.

Please list any vitamins or supplements you are currently taking. *

Enter "none" if you aren't currently taking any vitamins or supplements.

Allergies to Medications

Do you have any severe or potentially life-threatening allergies that would require the use of an epi pen?

Yes
No

If you answered "yes" to this question, please be sure to bring an epi pen with you.

Please describe your allergies.

If you answered "yes" to the above question, please describe in detail your allergies. If this does not apply to you, write "none".

Please list any recreational drugs you currently use. *

Enter "none" if you do not currently use any recreational drugs.

Please list any recreational drugs you have used in the past. *

Enter "none" if you have not used any recreational drugs in the past.

Are you currently pregnant? *

Yes
No

Pregnancy Disclaimer: I understand that sacred plants are purgatives and dangerous to consume while pregnant. If I become pregnant before the beginning of the retreat, I understand that I am responsible for notifying Green Heart and that I will not be able to ingest any sacred plant during pregnancy. I also understand that I will only be entitled to a refund if the conditions of the Cancellation Policy are met. *

By clicking here, I agree with the above.

Family Medical History

Family Medical History Details *

Please provide details if you check any condition. Enter "none" if none of the above have been checked.

Green Heart Health Screening & Full Disclosure: Because some of our tours involve the ingestion/utilization of sacred plants and Kambo, we carefully screen each guest for their safety prior to attending a tour. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) must be disclosed and subsequently approved for use by Green Heart. All herbal supplements, natural medicines, and medications (prescription and over-the-counter) cannot be taken during the course of the tour without the express permission of retreat leaders. You hereby agree that all information you provide in the application is correct and current and that you have disclosed all physical and psychological conditions as well as all herbal supplements, natural medicines and medications (prescription and over-the-counter) that you are taking. In some cases, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. Green Heart is not a medical facility and its owners, staff, employees and agents are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, we function as spiritual guides and teachers and offer ceremony for the purpose of spiritual communion. Dietary & Behavioral Restrictions: Because some of our tours involve the ingestion of sacred plants, there are certain dietary and behavioral restrictions that must be followed. You will be advised of these restrictions when you arrive at the start of the tour. Some of our tours may have a different set of restrictions than contained in the following paragraphs. Each specific set of restrictions should be followed according to the corresponding tour. The amount of sweets that can be consumed on tour due to the use of sacred plants is limited. Consumption of alcohol and street drugs are not allowed at any time during the tour. Consumption of red meat is not allowed during the entire tour and for 7 days after your last shamanic ceremony with sacred plants. You must also abstain from alcohol consumption and the use of street drugs for 7 days after your last ingestion of sacred plants. There is to be no sexual activity whatsoever between guests and/or staff during a tour. This includes married couples. This also includes masturbation. The environment demands abstinence from all sexual activity. Should you develop a sexual or romantic interest in another person, we request that you delay any physical displays or expressions of it until the tour is over. We are not attempting to create a moral or philosophical boundary but preventing the potentially dangerous crossing of energetic fields that can result from sexual or romantic behavior while engaged in shamanic ceremonies. Again, it is not important for the guest to understand this completely, but it is mandatory that the guest observe the rules.

Check this box if you agree to the Green Heart Health Screening and Full Disclosure.

Green Heart Medications Note: For your safety the Green Heart shamans have a "no medications / vitamins / supplements policy" during the retreat (with the exception of birth control pills). Medical studies have shown that mixing medications and some supplements, with sacred plants can be dangerous and potentially fatal. Green Heart representatives are not licensed to give advice on prescription medications. If you are currently taking medications, please consult with your doctor before discontinuing any medications. If your doctor approves discontinuing your medications and has guided you on the weaning process then we require that most medications need to be fully stopped at least one month before the workshop begins so that your physiology can find safe balance without it. This stability period could be extended up to 6 months depending on the combinations and types of medications being taken.

Check this box if you agree to the Green Heart Health Medications Note.

Have you attended a Green Heart retreat before? *

Yes
No

How many times?

When was the last time?

What were the results?

Have you attended a sacred plants retreat with anyone else? *

Yes
No

With whom?

Where?

When?

How many times?

What were the results?

Please read and agree to the terms indicated here: By checking the box and typing my name in the field below, I attest that I have read and understand all of the above written medical information and have openly disclosed all requested health and medical facts. I attest that the information provided above is true and complete, to the best of my knowledge. I understand that falsifying or omitting any relevant information may be grounds for denying my attendance at the workshop for which I am applying, with or without a refund, at the sole discretion of Green Heart, I hereby waive, release and hold harmless Green Heart from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the workshop. *

I accept the terms and conditions.

Please type your name in CAPITAL letters: *