Guest Profile & Deposit Form

First Name

Last Name

Email Address

Confirm Email Address

Phone Number with Area Code & Country CodeCity and country where you reside:AgeEmergency Contact NameEmergency Contact Phone (Area Code & Country Code)Second Emergency Contact NameSecond Emergency Contact Phone (Area Code & Country Code)Start Date of RetreatType of Room Desired (based on availability)Private Room/Private Bath- $5450ppPrivate Room/Shared Bath- $4950ppShared Room/Shared Bath- $4550 (family & friends only)Relationship StatusSingleDatingPartneredMarriedDo you consider yourself...

Physically Healthy

YesNo

Mentally Healthy

YesNo

Spiritually Healthy

YesNo

Have you taken other psychedelics in the past?

Iboga

YesNoMedicinallyRecreationally

Ibogaine

YesNoMedicinallyRecreationally

Ayahuasca

YesNoMedicinallyRecreationally

Psilocybin

YesNoMedicinallyRecreationally

Peyote

YesNoMedicinallyRecreationally

San Pedro/Huachuma

YesNoMedicinallyRecreationally

5MEO/DMT

YesNoMedicinallyRecreationally

LSD

YesNoMedicinallyRecreationally

Other

YesNoMedicinallyRecreationally

Heart Requirements

Our doctors look for specific requirements for heart health. We require a current EKG (within last 6 months) and our doctors will review and confirm if you are a viable canidate. It is very very rare that someone will discover an issue they didnt know about but it does happen on occasion. Depending on the severity we can sometimes administer lighter doses of medicine. There is a very small percentage who are unable to participate in the ceremony but this is typically someone who already has known heart issues.

Will you be getting an EKG before you arrive or with our doctor onsite? If you have ever had a heart condition in the past you MUST acquire before you arrive.

I have had one in the last 6 months. $30 payable upon arrival. PLEASE email results (If you do not pass requirements the standard cancellation policy applies)With your doctor onsite: $100 USD (if heart is slightly compromised you can still participate in the retreat with perhaps smaller amounts of medicine- no refunds will be given).Please list any surgeries including reason and date.Please list any visits to a mental health or drug detox facility including reason and date.Do you suffer from?

Asthma

YesNo

Sleep Apnea

YesNo

Chest/Heart Condition

YesNo

Liver Condition

YesNo

Kidney Condition

YesNo

Insomnia

YesNo

Skin Problems

YesNo

Candida

YesNo

Viral Infection

YesNo

Cognitive Problems

YesNo

Joint Pain

YesNo

Back Pain

YesNo

Weight loss/gain

YesNo

Intestinal Problems

YesNo

Thyroid Conditions

YesNo

High Blood Pressure

YesNo

Chronic Infections

YesNo

Bowel Problems

YesNo

Respiratory Issues

YesNo

Circulation Problems

YesNo

Other

YesNo

Please list any other medical conditions.Are you taking any of the following?

Heroin/Fentanyl

YesNoPhysically Dependent

Cocaine

YesNoPhysically Dependent

Methamphetamine

YesNoPhysically Dependent

Cannabis

YesNoPhysically Dependent

Alcohol

YesNoPhysically Dependent

Pharmaceuticals

YesNoPhysically Dependent

List any other prescribed medications, recreational drugs and/or over-the-counter medications (including vitamins, herbs, inhalers…). Please include details such as type, dose, and quantity.AlcoholDo you drink alcohol?

YesNo

If "yes", please answer the following 4 sections:What kind of alcohol do you drink?How many drinks per week?

Are you physically addicted to alcohol?

YesNo

Have you considered stopping?

YesNo

Have you ever experienced blackouts?

YesNo

Are you prone to "binge" drinking?

YesNo

Do you suffer from DTs or shaking if you stop drinking?

YesNo

Have you had a Liver Panel test in the past year?

YesNo

Do you suffer from?

Phobias or OCD

YesNo

Suicidal Thoughts

YesNo

PTSD/Trauma

YesNo

Panic Attacks

YesNo

Hearing Voices

YesNo

Psychotic Breaks

YesNo

Eating Disorder

YesNo

Dietary InformationDo you avoid any food groups?

Dairy

YesNo

Gluten

YesNo

Eggs

YesNo

Tree Nuts

YesNo

Peanuts

YesNo

Soy

YesNo

Animal Proteins

YesNo

NONE

YesNo

Other

YesNo

Do you have any food allergies?

Dairy

YesNo

Gluten

YesNo

Eggs

YesNo

Tree Nuts

YesNo

Peanuts

YesNo

Soy

YesNo

NONE

YesNo

Other

YesNo

If you answered "Yes" to any of these please explain.Do You Drink Caffeine? If you drink more than 2 cups daily we strongly encourage you to taper down 2+ weeks before the retreat so as to avoid caffeine withdrawal during the ceremony.None1-2 cups daily3-4 cups daily5+ cups dailyDo You Use Tobacco Products? Please list type and frequency. PLEASE NOTE: our retreat is "smoke free" apart from a specific spot outside our common areas. NO EXCEPTIONS :)Terms & ConditionsCancelation Policy
If you decide to leave AYS, before your retreat is completed, no full or partial refunds will be credited. You will also be responsible for you return airport transfer.

* Deposit is non-refundable. However, it can be transferred to a future date or to another person who wishes to participate (providing they are in appropriate health and pre-screened by our staff) We are a very intimate retreat with limited space. If you decide to reschedule to a different date (within one year) the following parameters will apply:

14+ days notice – 50% of deposit is transferable
0-13 days notice – 0% of deposit is transferable

** Like anything, there are risks, just as there would be crossing the street. By submitting a deposit you are confirming your understanding that participating in any retreat activities such as ceremonies, nature outings, swimming, etc. have inherent risks, dangers and hazards and participation in such outings or events may result in injury or illness.

Awaken Your Soul and each of its present and former owners, principals, members, agents and employees are not liable for damage, losses or personal injury resulting from participation in any aspect of our retreat.

*** Awaken Your Soul does a thorough screening of each participants physical, mental, emotional and spiritual state. By submitting this deposit you agree that you are fit to participate in this retreat. AYS is not responsible for your experience with the medicine itself. We create the space for you to do your own work and greatly support your process along the way. How you choose to listen to the information shared is up to you. No refunds or credits will be given based on whether the medicine did or did not "work".By checking this box I agree to AYS Terms and Conditions.Drug PolicyYou hereby understand and agree that if you are taking any prescription or street drugs that we previously communicated are unsuitable for Iboga. If you arrive for the retreat and are still using, your balance will be due in full and you will excluded from taking Iboga. Circumstances will dictate if you may still be invited to enjoy the retreat program without the medicine.

NO other plant medicines, drugs or alcohol are permitted on our premises or are to be used during your stay with AYS.By checking this box I agree to AYS Drug Policy.Commitment to Our SanctuaryOur main goal is to create a warm, safe, loving and healing environment for all to enjoy. We value all guest's experiences, healing processes and personal boundaries. We expect our guests do the same. The following behaviors are intolerable, and will result in being sent home without a credit for your stay at the sole discretion of AYS staff:

Consistent behaviors that significantly interfere with the healing process of other guests
Use of substances/drugs of any kind taken during your stay with us
Sexual harassment toward staff or other guests
Behavior that puts your own or others safety at risk
Theft of any kind

By checking this box I agree to The Commitment to Our Sanctuary.DepositsDeposits can be submitted in three ways- email to complete the deposit will arrive when this form is submitted.Zelle Pay (free through your bank if they offer)Bank Wire (+ any applicable fees from your bank)Bitcoin (BTC) and Etherium (ETH) (We will send you an address once you confirm this method of payment)To complete your registration you must click the link to submit deposit via the Deposit Instructions page that you'll be directed to once you hit "submit" down below.

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