Gutschein CORE-RETREAT

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1 Welcome

2 Sleeping area

3 People in your group

Guest 1		First Name* Last Name* Email* Gender*
Guest 1		First Name* Last Name* Email* Gender*

After completing this form, emails will be sent to everyone in your group to complete their information.

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4 Optional Items

5 Participant Info

Phone *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Email newsletter	Please send me the email newsletter
Comments or Special Needs
Gender *
Birth Date *
Requested Roommate
Special Diet
Diet Notes
Emergency contact: Name and telephone number *
Agreements on seminar participation *	I have read the agreements on seminar participation and agree to themYou find the agreements for seminar participation here
Consent to data storage *	I consent to the storage of my dataYou find our privacy policy here
Are you currently suffering from an illness or health problem? *
Describe your illness. *
For how long? *
Are you undergoing medical or therapeutic treatment? *
For what reason?? *
Have you had an operation in the last two years? *
Why and when did you have the operation? *
Are you taking medication? *	Please also note chemical sprays (nasal spray, asthma spray), lozenges and painkillers!
What medication are you taking and how often? *	Please also list chemical sprays (nasal spray, asthma spray), lozenges and painkillers!
Will you stop taking your medication before the retreat? *	If you are unable to stop taking your medication, please contact us at info@ayahuasca.at so that we can clarify this with our doctor!
Do you have a cardiovascular disease? *
Describe your cardiovascular disease. Medication? *
Have you ever had an infarction? *
Describe the infarction. Medication? *
Do you have high blood pressure? *
Describe the situation with your high blood pressure. Medication? *
Do you have digestive problems? *
Describe the situation with your digestive problems. Medication? *
Do you have a respiratory disease? *
Describe the situation with your respiratory disease. Medication? *
Do you have a mental illness? *
Do you have musculoskeletal problems? *
Describe the situation with your musculoskeletal problems. Medication? *
Do you have neurological or sensory problems? *
Describe the situation with your neurological or sensory problems. Medication? *
Describe your mental illness. *
Are you in psychiatric treatment? *
Do you have suicidal thoughts? *
Do you have Diabetes? *
Describe your diabetes. *
Do you have an autoimmune disease? *
Describe your autoimmune disease. *
Do you have specific allergies? *
What allergy(ies) do you have? *
Do you take nutritional supplements? *
What supplements do you take? *
Are you addicted to substances? *
What substances are you addicted to? *
Do you have experience with ayahuasca or other mind-expanding substances? *
What substances have you had experience with? *
What do you want to achieve through the ayahuasca experience? *	Share you motivation and your intention for your personal developement.
Have you decided to take part in our retreat out of your own motivation? *	It is important that no one has persuaded you to take part.
Reasons for exclusion and preparation read and understood *	I have read and understood the information on the reasons for exclusion and preparationBe sure to read the reasons for exclusion here Here you can find information on the mandatory preparation
Consent to extraordinary membership of the association *	I agree to become a supporting member of the non-profit organization AyaVision for one year in the course of my participation in the seminar.Membership of the association is a prerequisite for participation in the retreat, is valid for one year from the date of submission and does not entail any further obligations. It serves to legally secure the non-profit association's activities.

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7 Payment

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