Informed Consent

PLEASE READ THIS FORM CAREFULLY.
THIS IS A BINDING LEGAL DOCUMENT.

This agreement, between myself and the representatives of the 'Church of the Celestial Heart' (the "Church"), represents informed consent to participate in a ceremonial Ayahuasca (or Daime) ritual.

I understand that Ayahuasca (the Daime) is a powerful, mind and mood-altering beverage, and I am voluntarily participating in this religious, devotional ritual to advance my spiritual awareness and for my own personal growth, knowledge, and healing.

I know I may experience a range of psychological, emotional, and/or physical symptoms when drinking Ayahuasca (the Daime), including but not limited to nausea and vomiting, dizziness, fear, sadness, euphoria, confusion, disorientation, and other potentially disturbing experiences. I agree to ask a guardian/representative of the Church for assistance if I am in distress.

I am an adult of sound mind, physically and mentally healthy enough to endure this experience.

I have disclosed to the Church all medical and psychological conditions I currently have or recently had and all medications or drugs, including alcohol, I currently take or recently took. I also declare and agree that I will inform the church should there be any change in the information provided or in my health status before, during, or after ceremonies and prior to any subsequent ceremonies I might wish to join.

I am not currently diagnosed with any mental disorder or psychotic condition, nor have I been treated for one within the past eight years, nor have I written permission from a psychiatrist to participate despite my diagnosis. I do not currently have any medical or psychological condition that would make my participation a danger to myself or to others. Any uncertainty about this has been resolved with my personal physician and has been informed to the Church.

I do not currently take, nor have I recently taken, an MAOI (monoamine oxidase inhibitor), any drug-related to amphetamines, or any other prohibited substance. I understand taking these substances within several days of ingesting Ayahuasca or Daime could endanger my health and the health of those around me.

The Church of the Celestial Heart is not responsible for any decision made by me to stop taking medication or for changing my medication schedule. The Church of the Celestial Heart accepts no liability for any adverse effects from doing so. I acknowledge that the Church of the Celestial Heart or its representatives have advised me to seek medical advice and/or supervision from my prescribing doctor before reducing, ceasing, or changing any medication.

I agree to abstain from alcohol, fermented dairy, and all mind-altering substances for the required amount of time before and after the ceremony (3 days - 2 weeks, depending on the substance).

I have disclosed to the Church any history of aggression or violence I may have.

I have disclosed to the Church any history of suicidal thoughts or attempts I may have.

In the unlikely event of a psychotic episode or adverse reaction to the sacrament, I agree that the Church of the Celestial Heart reserves the right to offer care and follow its emergency protocols as deemed fit by the facilitation and staff, with the support of the emergency contact I have provided during my application process. This may include but is not limited to, retaining me onsite for monitoring and liaising with local emergency medical and hospital facilities.

I have been fully oriented to the ceremony experience, including a chance to ask questions of the Church representatives and the requirements for preparation in the days before the ceremony.

I agree to stay for the entire duration of the ceremony, including the sharing circle after the ceremony concludes. I have made arrangements for transportation after the ceremony, or I agree to stay until I am no longer under the influence of the sacrament before driving.

I agree and consent to keeping the confidentiality of all participants and agree to refrain from bringing any form of recording equipment, including a mobile phone, into the ceremony.

I consent and willfully agree to hand over my phone and car keys for the duration of the ceremony. I understand this is done for my own safety as well as the safety of the other participants.

I agree and consent to respect the guidance of the ceremony facilitators and staff of the Church of the Celestial Heart. I agree and consent to respect all participants, refraining from any form of sexual harassment, including verbal/non-verbal insinuation and physical contact.
Note: We maintain a zero-tolerance policy against sexual harassment.

I understand and agree that the terms of this Agreement are binding and contractual and agree to hold harmless the ‘Church of the Celestial Heart’, including all of its founders, staff, family, members, volunteers, associates, employees, agents, successors, and other participants. I further agree to defend and indemnify them from any claims, suits, and demands. I understand that this agreement is binding upon me, my spouse, parents, family, heirs, executors, administrators, agents, and assigns.

I HAVE READ AND UNDERSTAND THIS AGREEMENT  HAVE HAD TIME TO
REFLECT UPON IT, AND HEREBY SIGN THIS AGREEMENT  VOLUNTARILY.