9 Day Healing Immersion Ayahuasca & San Pedro Retreat El Camino Sagrado, Peru (Guest Application Form)

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Important Note:
After you apply, you will be taken to a booking page to schedule a phone call with us.

Please ensure you book this phone call immediately, as this is a necessary step to ensure there is a right fit for you to join us; for your safety and all our guests.

Complete the application below, and we look forward to connecting with you!

Tell Us About Yourself

First Name *
Last Name *
Email *	If you have completed a form with us in the past, please enter the same email address you previously used
Gender
Phone	Please include your country code, if outside of the US/Canada
Birth Date
Preferred retreat? *
Preferred retreat? - second choice
Emergency Contact Info *	Please enter full name & phone number
Have you intentionally worked with Ayahuasca or other Psychedelic Plant Medicine before?	If so, please elaborate.
Are you currently taking any medication, herbs or supplements? *	If so please outline what, how much and how often (please be as detailed as possible here)
Women: Are you pregnant or breastfeeding?
Please describe any medical conditions, diseases or injuries, past and present	This includes psychological as well as physical ailments
Do you have any history of depression, anxiety, psychosis, bipolar illness, schizophrenia or ADHD?	Please note that ceremonies should not be seen nor are they designed as a substitute for psychiatric or other medical care.
Do you have any specific dietary needs, allergies, intolerances, vegan, vegetarian etc?
Would you be interested in adding a two-day Machu Picchu Extension to your retreat? (+$400)	Yes please No thank you
Additional notes - anything else you want to mention?
Terms & Conditions (Application) *	I agree to the Ayahuasca Healings Retreats - Guest Guidelines and CommitmentsBy checking the above you acknowledge that you have read and agree to our Ayahuasca Healings Retreats - Terms and Conditions