Kambo Rejuvenation Detox Retreat

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1 Welcome

2 Price

	$75.00 to $200.00 – Please contact us, connect@truthisone.net, if you need a full scholarship
	$ Please enter an amount *

3 People in your group

Guest 1		First Name* Last Name* Email Address* Gender Identification
Guest 1		First Name* Last Name* Email Address* Gender Identification

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4 Personal Information

Transparency agreement	I have read and agree to the following statement:For the safety and consideration of all involved, I will be as honest and as transparent as possible when answering these questions. If any potential medical contraindications are present, I understand that Truth is One Interfaith Church will reach out to ensure my safety and that any information I share will be held in confidentiality.
Middle Name
Are you a veteran or in active duty?	We ask this question because we offer veteran/active duty specific programming.
Are you a veteran or in active duty?
Are you interested in learning more or participating in our Veterans Program?
Please tell us a little about your past / present military service.
Full Mailing Address (including state and zip code)
Address 2
City
State/Prov.
Zip/Postal
Country
Gender Identification
Height
Weight	Please note: Persons with a BMI of 32 or higher will not be able to attend as obesity is safety risk for this work. We are available to offer health and consultation services to assist with lifestyle changes and weight management to prepare for future ceremony work.
Occupation
Emergency Contact Name	Please enter the name of an emergency contact who will NOT be attending the ceremony.
Relationship to Emergency Contact
Emergency Contact Phone Number
Who referred you to Truth is One Interfaith Church?
Are you currently on our email list?
If you are not on our mailing list and you would like to be added, please fill out the New Member Application under the "join us" tab at truthisone.net.	https://truthisone.net/join-us/
If no, would you like to be added to our email list to receive our newsletters about upcoming events?

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5 Medical Information

Have you ever been in counseling with a psychiatrist, psychologist, or other counselor?
Check reason/s for counseling:	Depression Anxiety Career Academic Divorce Family Relations and Concerns Substance Abuse Suicide Related Issues Other
If you selected "Other," use this section to tell us more:
Check any that apply to you now or have applied to you in the past:	Allergies Diabetes Heart Condition Substance Abuse Within the last 5 years: hospitalization or needed medical treatment for any medical condition, psychological condition, or disability? Currently Pregnant- 1st trimester Currently Pregnant- 2nd trimester Currently Pregnant- 3rd trimester Currently Nursing Fainting Dizziness/Vertigo Seizure Physical, sexual, or emotional trauma Depression Bi-Polar Personality disorder Psychotic episode Anxiety Chronic Medical Condition Acute Medical Condition A medical condition not listed here Suicidal thoughts, ideation or attempt None of the Above
Use this section to provide details about anything you checked:	If you checked "None of the above," type N/A here
Check all that you are currently taking/using:	MAOI SSRI Amphetamine Asthma inhaler Antipsychotics Tranquilizers Barbiturates Opiates Prescription Medication Not Listed Here Over the Counter Medication St. John's Wort Nutmeg Kava Kratom Ephedra Ginseng Yohimbe Sinicuichi Rhodiola Rosea Kanna Boswellia Scotch Broom Licorice Root Cannabis Other Herbs, Supplements or Homeopathic Medicines Not Listed Here Alcohol Cocaine Crack Heroin/Opiates LSD MDMA/Ecstasy Psilocybin Other Recreational Drugs or Medicines Not Listed Here None of the Above
Use this section to provide the following details about anything you checked: 1. Dosage 2.Giving type 3.Frequency of use 4.Last usage:	If you checked "None of the above," type N/A here
Do you have dietary restrictions?
Use this section to provide details about your dietary restrictions:

6 Personal Development and Intentions

Have you sat with this community before?
Healing and Self Transformation are the purposes of this work. What types of personal, spiritual, and/or physical healing are you looking for in your life right now? What is your intention for this ceremony?
Do you currently have a spiritual practice?
Tell us about your practice:
Are you familiar with any practices of meditation, insight, or contemplation?
Tell us about your familiarity with these practices:
Do you have any experience with modified states of consciousness?
Tell us about your experience:
Do you have any experience with traditional ceremonial use of sacramental plants or shamanic techniques?
Tell us about your experience:
Do you facilitate any spiritual/ceremonial events?
Tell us about the spiritual/ceremonial events that you facilitate:
Do you have any concerns not indicated in this questionnaire?
List your questions here:
Additional Comments or Special Needs

7 Please Note

8 Agreements

General Waiver, Liability, and Payment *	I have read and agree to the following terms stated here:During my attendance at meditation sessions, I willingly agree to abide by these guidelines: Keep noble silence. Stay in the place designated until meditation is closed. Follow all instructions of the facilitators and helpers during meditation. I hereby agree that I always have a choice whether or not to participate, and I agree to take full responsibility for the choices I make involving this work during and after the event. I understand that this work may be physically, mentally, emotionally, or spiritually demanding, and I freely choose to enter this process. I accept full responsibility for whatever may occur, anticipated or unanticipated. To maintain the safety and trust for all participants, I hereby agree to hold this work confidential. I will reveal to no one the identity of persons participating in the event. This includes maintaining confidentiality for all facilitators, helpers, participants, and venue involved. I agree not to hold the facilitators, organizers, and the owners of the venue responsible for any damages or problems that might occur in any way connected with this meditation. If I receive individual preparation and integration sessions, I understand that the facilitators are not licensed therapists and that the support offered will vary depending on the facilitators experience and training. I agree not to hold Truth is One Interfaith Church or the facilitators responsible for any damages, harm or problems that might occur in relation to individual preparation and integrations sessions. I hereby knowingly and voluntarily assume the full risks of any physical or other injury, damage, or losses, either to myself or caused to others by me. I hereby waive the liability of, and agree to hold harmless, the organizers and facilitators of this meditation session as well as other staff, participants, and those who own and operate the venue. I release the facilitators and organizers from any responsibility for mental or physical damage to my person. I am fully responsible for the consequences of my participation before, during, and after the meditations. If I purchase something or receive additional services at the meditation such as Kambo Frog Medicine, staying an extra night, etc., or if I have a remaining balance, I understand that my credit card on file will be charged for these additional items/services/balances. All deposits are non-refundable. Refunds and credits may be given on a case by case basis and are not guaranteed. Payments must be made in full 1 week prior to the event. I understand that if I am signing up less than 1 week before the event, full payment must be received at the time of registration. If cancellation occurs within 72 hours of the event, all charges are non-refundable and the total cost of the program will be charged to the card on file. I will notify Truth is One of any illness or condition I may have that these questions might not address. It is my responsibility to inform the facilitators of any changes in health, any new conditions that may arise, and any changes in medication (including over-the-counter drugs, herbs, and supplements) between now and the meditation I wish to attend. I understand that Truth is One Interfaith Church is a registered, non-profit church in the State of North Carolina. When I register for an event, I am agreeing to become a member of Truth is One Interfaith Church.

General Waiver, Liability, and Payment *

I have read and agree to the following terms stated here:During my attendance at meditation sessions, I willingly agree to abide by these guidelines: Keep noble silence. Stay in the place designated until meditation is closed. Follow all instructions of the facilitators and helpers during meditation. I hereby agree that I always have a choice whether or not to participate, and I agree to take full responsibility for the choices I make involving this work during and after the event. I understand that this work may be physically, mentally, emotionally, or spiritually demanding, and I freely choose to enter this process. I accept full responsibility for whatever may occur, anticipated or unanticipated. To maintain the safety and trust for all participants, I hereby agree to hold this work confidential. I will reveal to no one the identity of persons participating in the event. This includes maintaining confidentiality for all facilitators, helpers, participants, and venue involved. I agree not to hold the facilitators, organizers, and the owners of the venue responsible for any damages or problems that might occur in any way connected with this meditation. If I receive individual preparation and integration sessions, I understand that the facilitators are not licensed therapists and that the support offered will vary depending on the facilitators experience and training. I agree not to hold Truth is One Interfaith Church or the facilitators responsible for any damages, harm or problems that might occur in relation to individual preparation and integrations sessions. I hereby knowingly and voluntarily assume the full risks of any physical or other injury, damage, or losses, either to myself or caused to others by me. I hereby waive the liability of, and agree to hold harmless, the organizers and facilitators of this meditation session as well as other staff, participants, and those who own and operate the venue. I release the facilitators and organizers from any responsibility for mental or physical damage to my person. I am fully responsible for the consequences of my participation before, during, and after the meditations. If I purchase something or receive additional services at the meditation such as Kambo Frog Medicine, staying an extra night, etc., or if I have a remaining balance, I understand that my credit card on file will be charged for these additional items/services/balances. All deposits are non-refundable. Refunds and credits may be given on a case by case basis and are not guaranteed. Payments must be made in full 1 week prior to the event. I understand that if I am signing up less than 1 week before the event, full payment must be received at the time of registration. If cancellation occurs within 72 hours of the event, all charges are non-refundable and the total cost of the program will be charged to the card on file. I will notify Truth is One of any illness or condition I may have that these questions might not address. It is my responsibility to inform the facilitators of any changes in health, any new conditions that may arise, and any changes in medication (including over-the-counter drugs, herbs, and supplements) between now and the meditation I wish to attend. I understand that Truth is One Interfaith Church is a registered, non-profit church in the State of North Carolina. When I register for an event, I am agreeing to become a member of Truth is One Interfaith Church.

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9 Signature of Acknowledgement

Today's Date
In typing my full name here, I acknowledge all questions and statements above:
Email newsletter	Please send me the email newsletter

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First Name
Last Name
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

1 Welcome

2 Price

3 People in your group

4 Personal Information

5 Medical Information

6 Personal Development and Intentions

7 Please Note

8 Agreements

9 Signature of Acknowledgement

10 Donate

11 Payment