Sophia Waiver & Medical Form

WAIVER

This release says that you know that participating in an entheogenic ceremonial work may involve discomfort and unexpected physical, mental or emotional upset. By signing this release agreement you are waiving all rights to seek or receive compensation in any case of injury, loss or damage.

I understand that although my participation in this ceremony is purely voluntary, I agree to remain until the closing of any ceremony of which I choose to begin.

During the work, I will ingest and entheogen(s). I have been informed of the type and its effects as well as the objectives of taking it within this ceremony. I have been attracted to this work as a result of research, personal reports, as well as the potential for profound spiritual experience. I understand that the facilitators make no claim or promise regarding the curing of illness or the nature of any spiritual experience. I understand that the ceremony is personal and sacred to each individual.

I understand that I may be physically or mentally exhausted and/or disoriented after this ceremony. I acknowledge that it is my responsibility to arrange alternate transportation if it is needed.

I hereby acknowledge and voluntarily assume the full risks of any physical or other injury, damage or losses, either to myself or caused to others by me during any of the ceremonies organized by or on the property of the facilitator(s). I hereby waive the liability of and agree to hold harmless the facilitator(s), the organization, including all of its founders, members, associates, employees, agents, staff, family, successors, volunteers, and other participants. I further agree to defend and indemnify them from any claims, suits, or demand. I understand that this agreement is binding upon me, my
spouse, parents, family, heirs, executioners, administrators, agents and assignees.

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I HAVE READ AND UNDERSTAND THIS WAIVER, HAVE HAD TIME TO REFLECT UPON IT, AND SIGN THIS WAIVER VOLUNTARILY. Please fill in your name to serve as your electronic signature and agreement: *

Name *

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Last

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Date of Birth *

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Have you been diagnosed with any chronic illnesses? If so, what? *

Do you have any allergies? *

Have you recently had any recent surgeries? If so, what and when? *

Do you have any physical ailments or restrictions? If so, what? *

Does your ailment require special considerations? If so, what?

Do you currently take any medications? If so what? (Please include nutritional supplements and herbs.) *

Do you take/use any of the following:

• MAOI’s
• SSRI’s
• Narcotic Analgesics
• Amphetamines
• Alcohol
• Recreational Drugs

Do you currently take or have your ever taken any other psychiatric medications? If so, what and when? *

Have you been hospitalized for a mental illness? If yes, what was your course of treatment and outcome? *

Have you been diagnosed with a mental illness? If yes, what was your course of treatment and outcome? *

Do you see a mental health practitioner of any kind? If yes, for what reason? *

Have you been arrested for a crime? If so, what? *

Is there anything else about your physical or emotional status we should know?

By checking this box: *

• I attest that all of this information is true and I agree to communicate any changes to my answers before attending any circle.

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