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Ayahuasca December Year End Retreat

December 10 - 16, 2017

Retreat Guru is the online booking agent for The Source Peru.

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Price

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$1,690.00 – Program Price

Participant Info

Personal Information

Emergency Contact Information

Dietary Preferences

Ensure that you inform us of all allergies/sensitivities now as we cannot accommodate you if you only let us know when you arrive onsite.

Physical Health History

It is imperative that you disclose all health conditions, whether mental or physical, in full at the time of application. Any preexisting physical condition must be cleared with your doctor. Failure to disclose existing medical conditions – either mental or physical – will result in your immediate termination from the retreat, without refund…even if you are already onsite with us when the information comes to light.
Enter "None" if no conditions apply.
Enter "None" if no conditions apply.
If you have such a condition, ensure that you bring an epi-pen with you!

Mental Health History

It is imperative that you disclose all health conditions, whether mental or physical, in full at the time of application. Any preexisting physical condition must be cleared with your doctor. Failure to disclose existing medical conditions – either mental or physical – will result in your immediate termination from the retreat, without refund…even if you are already onsite with us when the information comes to light.
Enter "None" if no conditions apply.

Family Medical History

Enter "None" if no conditions apply.

Medications, Supplements, Drug Use

For your safety and the safety of all others coming to Source Peru, we maintain a no drugs (prescription or recreational) or alcohol policy for any retreats involving plant medicine ceremonies. Combining medications, supplements and/or other recreational drugs with Ayahuasca can be dangerous and potentially fatal. Be sure to read our Medical Guidelines page to be clear about contraindications. It is imperative that you disclose all prescriptions, supplements and recreational drugs in full at the time of registration for the retreat. Further, if your status changes between the time of registration and the start date of the retreat, you must notify us immediately. Most medications must be stopped one month prior to the start of the retreat, especially anti-depressants and anti-anxiety drugs. Recreational drug use and alcohol should be stopped 2 weeks prior to the retreat. If you are currently taking any prescribed medications, please consult with your doctor before altering your intake of them in any way. Only if your doctor approves of altering these medications and has given you clearance may you attend. Failure to disclose your use of prescription medication or non-prescription drugs will result in your immediate termination from the retreat, without refund…even if you are already onsite with us when the information comes to light.

Military/Police Service

If you answer yes here, ensure that you explain the details in the PTSD question field in the Mental Health section above.

Alternative Medicine Experience & Intentions

If no prior experience, enter N/A
If no prior experience, enter N/A.
If no prior experience, enter N/A.

Payment

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Retreat Guru is the online booking agent for The Source Peru.
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Charges will appear on your bill as "RG *TheSource"