Kambo Frog Medicine & Waterfalls Rejuvenation Retreat

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1 Welcome

2 Price

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$875.00 – Kambo Medicine Rejuvenation Retreat: Retreat Package Fri. 6/7- Sun. 6/9: Includes: 3 treatments of Kambo Frog Medicine, communal accommodations, delicious vegetarian meals, sauna use and hot/cold therapy, waterfall visit, nature hikes, meditation, yoga, journaling exercises, authentic relating, sacred sound & live music

$200.00 – 1 Kambo Frog Treatment Drop-In

$400.00 – 2 Kambo Frog Treatments Drop-In

$600.00 – 3 Kambo Frog Treatments Drop-In

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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 Optional Items

5 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.
Please check which treatment date(s) you plan to attend:	Full Retreat Package: Friday March 8th- Sunday January 10th Friday March 8th: 10am-1pm Drop in Saturday March 9th: 10am-1pm Drop in Sunday March 10th: 10am-1pm Drop in
Full Mailing Address (including state and zip code) *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Birth Date *
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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6 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:

7 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? *
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: *
Truth is One Registry	We are compiling a registry so that members of our community can reach out to one another. If you would like to be included, please provide the name and contact information (email and/or phone number) you would like to share. *Please note: by responding to this question you are consenting to sharing the name and contact information you have listed above to other members of Truth is One. If you are not interested in being added to the registry, please leave this section blank. If you have previously filled out this information, you do not need to do it again. Thank you!
Do you have any concerns not indicated in this questionnaire? *
List your questions here:
Additional Comments or Special Needs

8 Agreements

General Waiver and Liability *	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. I understand that deposits are non-refundable and that if I paid more than a deposit and I can no longer attend, I must cancel 72 hours prior to the event to be eligible for a partial refund/credit. I understand that partial refunds/credits are not guaranteed. Payments must be made in full 72 hours prior to the event. I understand that if I am signing up less than 3 days before the event, full payment must be received at the time of registration. It is my responsibility to inform Truth is One Interfaith Church 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 and Liability *

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. I understand that deposits are non-refundable and that if I paid more than a deposit and I can no longer attend, I must cancel 72 hours prior to the event to be eligible for a partial refund/credit. I understand that partial refunds/credits are not guaranteed. Payments must be made in full 72 hours prior to the event. I understand that if I am signing up less than 3 days before the event, full payment must be received at the time of registration. It is my responsibility to inform Truth is One Interfaith Church 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 Coronavirus/COVID-19

COVID-19/Coronavirus *	I have read and agree to the following terms stated here:I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Truth is One Interfaith Church, Inc. has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that Truth is One Interfaith Church, Inc. can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, meditation facilitators, organizers, helpers, owners of the venue, participants and their families. I voluntarily seek services provided by Truth is One Interfaith Church, Inc. and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread of the virus while attending the meditations. I attest that:* I am not experiencing any symptom of illness including, but not limited to cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 14 days.* I have not traveled to a highly impacted area within the United States of America in the last 14 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

10 Signature of Acknowledgement

Today's Date *
In typing my full name here, I acknowledge all questions and statements above: *

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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

Kambo Frog Medicine & Waterfalls Rejuvenation Retreat

1 Welcome

2 Price

3 People in your group

4 Optional Items

5 Personal Information

6 Medical Information

7 Personal Development and Intentions

8 Agreements

9 Coronavirus/COVID-19

10 Signature of Acknowledgement

11 Payment