Rising Light New Era Kambo and Yoga Retreat Application

Legal First & Last Name:

Address

Phone:

Email:

Emergency Contact Name

Emergency Contact Number

Retreat of interest

Kelowna

Muskoka

Banff

Cardiovascular Disease

YES

NO

UNKNOWN

Heart Attacks

YES

NO

UNKNOWN

High Blood Pressure

YES

NO

UNKNOWN

Low Blood Pressure

YES

NO

UNKNOWN

Circulation Issues

Blood Clots

Vericose Veines

Spider Veins

Numbing of hands, arms, legs and/or feet

None

Depression

YES

NO

UNKNOWN

Anxiety

YES

NO

UNKNOWN

Surgery within past 12 months

YES

NO

Dental work within past 12 months (other than routine cleanings)

YES

NO

Past or Present Physical Injuries (ie concussions, torn ligaments)

YES

NO

Broken Bones

YES

NO

Transplant Recipient / Donor

YES

NO

Glaucoma

YES

NO

Retinal Detachment

YES

NO

UNKNOWN

Epilepsy / Seizure history

YES

NO

UNKNOWN

Family History of Epilepsy / Seizure

YES

NO

UNKNOWN

Asthma

YES

NO

UNKNOWN

Diabetes

YES

NO

UNKNOWN

Schizophrenia

YES

NO

Boderline Personality Disorder

YES

NO

UNKNOWN

Narcisistic Personality Disorder

YES

NO

UNKNOWN

Diagnosed Aspergers

YES

NO

Diagnosed Autism

YES

NO

Skin Conditions

YES

NO

UNKNOWN

Liver Issues

YES

NO

UNKNOWN

Intestines / Bowel / Digestive Disorders

YES

NO

UNKNOWN

Head or Neck Injuries

YES

NO

UNKNOWN

Sleeping Disorders

YES

NO

UNKNOWN

Bladder or kidney issues?

YES

NO

UNKNOWN

Back Injury

YES

NO

UNKNOWN

Are you pregnant?

YES

NO

UNKNOWN

Are you breastfeeding?

YES

NO

Are you taking birth control?

YES

NO

Are you currently receiving hormone therapy?

YES

NO

Will you be traveling 14 days prior to ceremony date in quesion?

YES

NO

Have you received the Covid 19 vaccine?

Have you had any adverse reactions to the vaccine?

YES

NO

UNKNOWN

If YES, please ellaborate

Infectious Disease

YES

NO

UNKNOWN

If yes, please elaborate on the current status of the condition

Have you been diagnosed with an autoimmune disorder?

YES

NO

If yes, please share with us which autoimmune disorder you have been diagnosed with

Are you currently taking prescription medication?

YES

NO

If yes, please list all the medications and what dose you are taking

Are you currently taking homeopathic remedies?

YES

NO

If yes, please list all remedies and what your regement is

Are you currently taking vitamins or supplements?

YES

NO

If yes, please list all vitamins, supplements and minerals you are taking

Are you currently using recreational substances?

YES

NO

If yes, please list all recreational substances you have consumed within the past 12 months

Are you currently taking any pain killers?

YES

NO

If yes, please list all pain killer medications you are taking and how often

Are you currently taking medication to quit smoking?

YES

NO

If yes, please list medication and dosing schedule

Do you have any allergies?

YES

NO

If yes, please list all allergies

Dietary Restrictions

Is there anything else we should know about your medical history before we can determine your safety in participating?

YES

NO

If yes, please write what you feel is important for us to know in order to determine whether it is safe for you to participate in our ceremonies

Have you sat with plant medicines before?

YES

NO

If yes, please list the ceremonies you have participated in and the approximate dates

List three things that are causing the most disruption in your life?

What would you rate your mood in the mornings?

What is your outlook on life?

How easily are you able to shift your mood?

How easily are you able to control your emotions?

Do you believe you are enough?

No

Maybe

Sometimes

Absolutely I am

List three thoughts that cross your mind each day

Where do you see yourself in 3 years?

I don't know

It scares me

I'm hopeful

I'm excited

What is your current emotional state?

Describe yourself in three words

What is your intention for participating?

Photography / Videography - Select ALL that apply

I understand that photos/videos may or may not be taken before, during and after ceremony and give consent to Rising Light Staff to take photos/videos/voice recordings of me for my own personal use ONLY

I understand that photos/videos may or may not be taken before, during and after ceremonyand give consent to Rising Light Staff to take photos/videos/voice recordings of me for promotional use of The Rising Light and their staff on the website and/or social media

I do NOT want photos/videos/voice recordings of me to be taken under any circumstance

I certify that my answers are complete and true to the best of my knowledge

YES

NO

I understand that in signing this form, I am agreeing to partake in a spiritual ceremony and that my admission is based on the information provided in this form

YES

NO

I am signing this form of my own free will and hold no liabitlity to The Rising LIght, their practitioners or other participants in the event that I have provided false or misleading information that is detrimental to my mental health and physical well-being

YES

NO

Opt-In

By checking, I understand that I am not guaranteed a spot until my form has been reviewed for participation and I have submitted a $500 deposit to secure my spot!

Please attach a photo of your government issued identification

Upload File

Digital Signature

Participation Application

Medical Form