Apply for a Gathering Rainforest Medicine Gathering ApplicationPARTICIPANT PRE-SCREENING & QUESTIONNAIREPlease respond to each question to give us an understanding of who you are, why you’d like to attend and how we can be of service.* RequiredEmail address *Your emailDahlia Miller *Your answerContact # *Your answerHow did you learn about this Rainforest Medicine offering? *Your answerEmergency Contact (Name & Relationship) *Your answerEmergency Contact # *Your answerSkype (if available) *Your answerBirthday *MM / DD / YYYYAge *Your answerGender *FemaleMalePassport expiration date *MM / DD / YYYYWhich country are you from? *Your answer *Because Costa Rican authorities require a yellow-fever vaccine certification from travelers of the following countries: Angola, Benin, Burkina Faso, Cameroon, Democratic Republic of Congo, Gabon, Gambia, Guinea, Liberia, Nigeria, Sierra Leon, Sudan, Bolivia, Venezuela, Brazil, Peru, Colombia, Ecuador and Guyana, even if you were only transiting (a stop-over) through any one of these countries. Please contact the Costa Rican consulate in your country to ask how many days prior to arriving into Costa Rica do they require that you have the yellow fever vaccination. If so, you must travel with your yellow fever vaccination card to show the Costa Rican officials at Santa Maria International in San José. If you are over 60 years of age, although you may be exempt from the vaccination, you must provide a doctor to sign off on a RX pad saying you are not advised to take the vaccination. For other exemptions, please read: http://www.costarica-embassy.org/index.php?q=node/97Your answerOccupation *Your answerWhat is your reason for attending? *Your answerDate of the event *MM / DD / YYYYDate and Time of International Arrival *MM / DD / YYYYTime:AMPMDate and Time of International Departure *MM / DD / YYYYTime:AMPMWhat type of experience have you had with entheogenic plants? *Your answerIs this your first time exploring the use of sacred ancestral rainforest medicine? (Banisteriopsis caapi and admixture preparations) *YesNoIf yes, how many times? *Your answerHow has your experience(s) been? *Your answerHow has your experience(s) changed your outlook on life? *Your answerPlease read this list, specifically "Food and Medication to Avoid." Have you read the list thoroughly? *http://www.ayahuasca.com/science/foods-and-meds-to-avoid-with-maois/YesNoHave you ever had / or are currently experiencing any of the following medical conditions (Please select all that apply): *AneurysmAngina/Chest PainAsthmaChronic PainCirculatory ProblemsCranial TraumaDiabetes/Pre-DiabetesHeart AttackHeart MurmurHeart SurgeryHigh Blood PressureHIV/AIDSInfectious DiseaseIrregular HeartbeatLow Blood PressureMeningitisMigrainesNeurological DiseaseObesityPhysical DisabilitySeizures (epileptic)Stomach UlcersStrokeTuberculosisNoneRequiredHave you ever had / or are currently experiencing any of the following mental conditions (Please select all that apply): *AutismBipolarBorderline Personality DisorderChronic AnxietyClinical DepressionDepersonalizationEating DisorderMultiple Personality DisorderObsessive Compulsive DisorderPost Traumatic Stress (PTSD)PsychosisSchizophreniaSuicidal TendencyNoneRequiredDo you have any health issues that you want us to be aware of? (Please list all, including any physical, mental, past injuries or traumas and their history.) *Your answerHave you ever been diagnosed, treated or self-diagnosed as an alcoholic or drug-addict? *YesNoIf so, please write a brief paragraph about any substances which you may have used or are currently using, how often you would use and your perceived relationship to them. *Your answerPlease list any pharmaceutical medications you are currently taking, or have taken within the past 6 months. *Your answerAre you currently taking, or have you recently stopped taking any form of antidepressants? If so, please write the name(s), dosage(s), duration and the date(s) you stopped. *Your answerWithin the past 6 months, have you recently stopped taking any natural supplements, herbal medicines or vitamins including St. John wort, 5-HTP, SAM-e, Kava or anything else listed on link above regarding foods and medications to avoid? If so, please list the names and dates you stopped taking them *Notes: The above meds-to-avoid can potentially make your ceremonial experience seriously contra-productive to your health. The foods-to-avoid in the above website are best to avoid at least 2 weeks prior to your rainforest medicine council date.Your answerDo you use Cannabis for medicinal purpose? Or for other reasons? if so, describe your usage. *Your answerDo you use other plants for medicine? If so, to what extent? Why are you using? and how do you feel they are helping you? *Your answer For women: Will you be expecting your menstrual cycle during the retreat? *If so, please consider participating on a different date, given that women on the moon time are not permitted to participate in the Ancestral Rainforest Medicine ceremony. If your menstrual cycle were to come unexpected, this is still the case. Please note though, we do have alternative activities for cleansing and healing that we can offer you if you choose to come to Guaria during a council.YesNoMaybeI am not a womanRequiredIf you are a woman and your menstrual cycle comes during the council, are you in consent that you will not be able to participate in the plant medicine ceremony until the cycle has fully passed? *Note: There are traditional regulations that prohibit the drinking of the medicine while on one’s moon cycle and there are very specific health reasons for this as well. Our intentions are to uphold the ancestral rainforest plant medicine ceremonies as they were transmitted and taught to us, which is a sound and safeguarded method. Likewise, a woman's menstruation is already a process going through Mother Nature's natural and powerful monthly cleanse. Aya is also a powerful cleanse. Both Aya and menses have an abundance of bright light energies challenging to the woman and others in ceremony. Therefore, we ask women to abstain from ceremony until her cycle is over. Thank you for understanding.Yes , I agree and can sit out until my menstrual cycle passes.No, I have issues with this and it would be difficult to agree to this.AGREEMENTS: I have fully read and understood the contra-indications, mentioned in the web page on foods and drugs to avoid, and I understand the potential implications of using certain pharmaceuticals with MAO-I's. I understand that these are strongly contra-indicated with rainforest plant medicines, and can be very dangerous and potentially fatal when combined. *I AgreeRequiredI have fully read and agree to practice the Dieta Protocol written up in the following document: https://rainforestmedicine.net/wp-content/uploads/2017/04/DIETA_PROTOCOL.pdf *I AgreeRequiredI will discontinue all use of alcohol, recreational/street drugs, non-prescribed pharmaceuticals, and contra-indicatory foods such as aged cheese and processed foods, excessive sugar consumption, at least two weeks prior to coming to a Rainforest Medicine Council. *I AgreeRequiredI have completed this questionnaire myself, have answered truthfully, and have not withheld or misrepresented any information. *I AgreeRequiredIf any new information arises which will affect or change this application, I will communicate this update to the council coordinator via email. *I AgreeRequiredIs there anything that you like to add to this application for us to better understand where you are coming from? *Your answerI release the facilitator, organizer and any/all people associated with Rainforest Medicine Councils from all actions, claims, demands or damages that may result from my participation. *I AgreeRequireddahlia miller Please type your name (electronic signature) *Your answerJan. 31, 2019 *MM / DD / YYYYA copy of your responses will be emailed to the address you provided.SubmitPage 1 of 1Never submit passwords through Google Forms.reCAPTCHAPrivacyTermsThis content is neither created nor endorsed by Google. 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