Kambo Medicine with Davi De Paula

IMPORTANT! If after reviewing your medical information, we discover it is not a good fit, we will refund your money. The refund may take up to 7 days.

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3 Optional Items

4 Participant Info

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Comments or Special Needs
Is this your first retreat or event with us? *
Have you ever taken any psychedelics before? *
Have you ever taken Ayauhasca before? *
How did you hear about us?
Email newsletter	Yes, please send me the email newsletter about future events and retreatsIf you prefer NOT TO be added to our mailing list to receive notifications about future retreats and events, uncheck this box above.
Cancelation Policy *	I agree to the cancelation policy. Please kindly take a note of our Cancelation Policy.   At Truth is One we take the time to prepare for every single retreat or event. When a person cancels without giving enough notice, that prevents others from taking the opportunity to participate. For cancellations 14 days or more before the retreat or workshop you will be issued a full refund For cancelations 10 days before we will issue 50% refund or a credit for another retreat or event For cancelation less or 7 days before the retreat or event no refunds will be issued To cancel, please send an email to: createchange@comunindios.com If for any reason we must cancel a retreat or an event due unforeseen circumstances, we we will issue a full refund or issue a credit for another retreat or event.
Liability Waiver *	I agree to the above waiver. I hereby confirm that I have read and understood the below information and have answered all the questions completely and honestly and have not withheld any information.I agree to the following waiver: I hereby confirm that I have read and understood the below information and have answered all the questions completely and honestly and have not withheld any information. I read and agree to the guidelines that I received regarding confidentiality, respect, safety diet, and spiritual diet and will contact my organizers and/or facilitators with any vital or crucial concerns before and after the ceremony or workshop. I will consult the facilitators regarding any possible contra-indications I may have to ingest any MAOI-containing substances prior to the ceremony or any medication I am currently taking. I release Truth is One Organization and all persons related to my participation in this ceremony, program, course or workshop from responsibility for anything that occurs to me prior to, during, or after a ceremony, including but not limited to any physical and/or mental injury or damage. I further agree to defend and indemnify all of the facilitators and/or organizers from any claims, suits and demands. This agreement is binding upon myself, my spouse, parents, family, heirs, executors, administrators, agents and assigns. I am participating in this ceremony on my own volition and as an expression of my freedom. I hereby provide my consent for the utilization of photographs and/or videos capturing my image during community workshops, courses, or programs. These visual materials may be used in various publications, social media platforms, news releases, online channels, and other forms of communication that align with the mission of the Truth is One Church. As a member and participant of the church, it is expected that I will refrain from directly or indirectly contacting any facilitators or practitioners. All communication regarding ceremonies or healing sessions should be directed through the staff of Truth is One. It is my intention to uphold a safe and sacred healing process for myself and all involved by not scheduling any ceremonies or healing sessions with facilitators or practitioners outside of the church. As a non-profit organization and healing institution, Truth is One places significant importance on maintaining the confidentiality of its participants and their healing journeys. I agree to protect and uphold the confidentiality of any information obtained from the functions held by Truth is One, which include details regarding participants, practices, ethics, workshops, events, ceremonies, and staff members. I will comply with relevant privacy regulations and ensure that such information is accessed solely by employees or representatives who have a legitimate need for it in fulfilling their responsibilities. If a dispute arises under this Agreement, the parties agree to waive their right to a judicial proceeding and to submit the dispute to a mutually agreed-upon arbitrator in Cook County, Illinois. Judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction to do so, in Cook County, Illinois. Arbitrator’s decision accepted by all parties as binding and final, and all parties subject to this agreement waive any rights to appeal to any Court. Costs of arbitration, including attorney fees, will be allocated by the arbitrator to the prevailing party. I agree that I was given the opportunity to retain independent legal counsel of my own choice and have either done so or elected not to obtain such counsel. I agree to not to disclose of any information about the ceremonies, procedures, documents and materials used by the Truth is One church. I understand that if I violate any portion of this agreement I may be subject to lawsuit or legal action and will be responsible for my own all legal costs and those of the prevailing party.

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5 Medical

Confidential Disclosure Your medical background is extremely valuable to us to ensure a safe process and it is strictly confidential.

Do you have any diagnosed illness, disease or psychological conditions? *
Please list all diagnosed illness, disease or psychological conditions.
Do you have any family history of illness, disease or psychological conditions? *	Yes No
Please explain:
Have you been diagnosed with bipolar or schizophrenia? *	NOTE: IF YOU HAVE BEEN DIAGNOSED WITH SCHIZOPHRENIA OR BIPOLAR, YOU CANNOT ATTEND THIS CEREMONY BECAUSE IT CAN CAUSE A LIFE THREATENING INTERACTION.
Have you ever suffered from any mental condition or mental illness? *	Depression Obsessive Compulsive Disorder Paranoia Psychosis Suicidal Tendencies/ Suicidal Thoughts Multiple Personality Disorder Chronic Anxiety PTSD Clinical Depression Borderline Personality Disorder Self Harming None of the above
Are you currently taking any medication? *
Please list any medications you are currently taking.	PLEASE MAKE SURE THAT YOU READ THROUGH THE PREPARATION DOCUMENT TO IDENTIFY THE INTERACTION OF YOUR MEDICATION WITH THE PLANT TEACHER. SOME PHARMACEUTICALS CAN BE LIFE THREATENING WHEN COMBINED WITH THE CEREMONY. PLEASE DO NOT STOP TAKING ANY MEDICATIONS WITHOUT DOCTORS SUPERVISION.
Do you have a past history of, or currently suffer from any of the following: *	Cardiovascular disease, including heart attacks High / Low Blood Pressure Recent surgery Past or recent physical injuries (fractures or dislocations) Glaucoma Epilepsy Infectious or communicable diseases Asthma Head Trauma Hepatitis A, B or C Kidney Diseases Postpartun Depression Sexual Trauma Tuberculosis Seizure History Hypoglycemia Cancer Gout Lukemia None of the above
If yes, please elaborate:
Have you dealt with any of the following emotional / behavioral problems? Check all that apply: *	Drug use Extreme worrier Impusivity Violent temper Hostile/angry mood Self-injurious acts Indecisiveness HIV/AIDS Drug Dependency None of above
Have you sought health advice from a certified medical professional regarding these medications or conditions and your participation in this event? *	Yes No
Is your adviser happy for you to take part?	Yes No
Are YOU happy to take part and to absolve us of responsibility and liability for any physical or mental adversities?	Yes No
Have you taken or currently take the following psychoactive substances or any other substances: *	Cocaine Crystal meth Crack Opium Morphine Heroine Marijuana Alcohol Hash Pills LSD MDMA (ecstasy, molly etc) None of the above FAILURE TO COMPLETELY ANSWER THIS QUESTION MAY RESULT IN A DELAY IN YOUR REGISTRATION. IT MAY ALSO CAUSE HEALTH HAZARD IF NOT DISCLOSED.
If yes, please list a substance and a date of your last consumption of the substance.
Are you willing and able NOT to use alcohol and marijuana for at least 3 days before the ceremony; cocaine, hash, opium, LSD, and MDMA for at least 2 weeks before the ceremony; and all other substances mentioned in the previous question for at least 2 months before the ceremony? Please note that all of the above substances can have serious and, at times, lethal interactions with the ceremony. *	Yes No NOTE: By checking NO, You are not willing to follow these guidelines and will not be allowed to participate in ceremony.
Are you on any special dietary program and/or restrictions? *	Yes No
Please elaborate:
Are you pregnant, suspect you are pregnant or are breastfeeding? *	Yes No
Please explain	How far along are you? Is there anything else we should know?
Do you have any allergies? *	Yes No
Please explain:
Please share if you have any disease, pathology, or functional problem not considered here
Are you currently taking ANY anti depressant medications OR supplements currently prescribed or self administered and the duration ? *
If yes, please list the dosage and length of time you have been taking them
Have you been diagnosed with any illness, disease or psychological conditions since your last ceremony with us? *
Please explain: *
Name *
Signed *
Dated *
Have you had a heart surgery in the last 6 months *
Have you had any major surgery in the last 6 months? *

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