Ceremony Release Form
I seek to participate in Ayahuasca Ceremony(ies). I understand that the facilitator’s desire to ensure the safety of all participants. I further understand that in order to assist in this regard, I agree to complete this release form and the confidential medical history form. I am assured that the information obtained herein is used to determine if it is appropriate for the undersigned to participate in this work. I further understand all information contained herein will remain strictly confidential.
PARTICIPANT ACKNOWLEDGMENT, ASSUMATION OF RISKS, LIABILITY RELEASE AND INDEMNITY AGREEMENT
General Provisions
This Spiritual Organization Participant Acknowledgement, and Liability Release Agreement (“Agreement”) is voluntarily entered into between the undersigned individual (“Client”) and __________________ (“Church”). This Agreement is intended to cover all activities by Client with Church as described below. The Agreement is effective as of the date signed below.
Client acknowledges and accepts Church has agreed to provide certain spiritual and harm reduction services including spiritual guidance, non-mental health coaching and non-medical coaching, harm reduction services, beneficial community-based use and healing, supported use, or other related services (“Services”) related to Client’s personal use of the Church’s Sacrament, ayahuasca. Church is not providing any medical or mental health services.
Spiritual Use and Religious Freedom
Client acknowledges and understands that the Services are part of a bona fide spiritual practice that Church believes are protected by various laws, including the Religious Freedom Restoration Act, and other religious liberty protections found in each state’s laws. The spiritual beliefs include that the use of Sacraments connect the Client to the divine source of the universe, to the divine within themselves, to the divine within others, and to the psycho-spiritual healing powers of Mother Earth and other protective spirits. Client either agrees with these spiritual views, or is open to the possibility that these Services are consistent with their spiritual path, by engaging in these practices.
No Guaranteed Results and Acknowledgement of Risks
Client understands that the Services may be transformational and, with or without the Services, create positive changes in mood, habits, and emotional state if engaged in with intention. However, Client understands and acknowledges that there are also risks associated with engaging in the Services, as discussed throughout this Agreement. Client understands that Church cannot and does not guarantee any particular outcome from the Services. Client acknowledges that they should seek independent medical advice from a qualified professional to determine if they are medically cleared to engage in activities related to Sacraments. Client acknowledges that Church is not selling or being compensated in any way for natural medicine and Client is only paying for the Church’s Services.
Client further understands and acknowledges that the use of Sacraments, such as psilocybin, to be undertaken or performed by Client may involve risks to Client including, but not limited, to: (i) risks inherent in the nature of the psilocybin as explained below, and (ii) risks caused or complicated by any mental, physical or emotions conditions any Client may have.
Dimethyltryptamine (“DMT,” the active ingredient in ayahuasca) Side Effects and Warnings
The main effect of DMT is psychological, with intense visual and auditory hallucinations, euphoria, and an altered sense of space, body, and time. Many users describe profound, life-changing experiences such as visiting other worlds, talking with alien entities, and total shifts in the perception of identity and reality. When smoked, DMT produces brief yet intense visual and auditory hallucinations that some users describe as an alternate reality, otherworldly, or a near-death experience. Possible side effects of DMT include:
increased heart rate, increased blood pressure, chest pain or tightness, agitation, dilated pupils, rapid rhythmic movements of the eye, and dizziness. When taken orally, DMT can cause nausea, vomiting, and diarrhea. Because DMT can mimic a near-death experience, some people may find using the drug traumatic and upsetting. Mental side effects may linger for many days or weeks after ingestion of the drug.
DMT is structurally related to the neurotransmitter serotonin. Heavy use, or use along with other drugs that contain serotonin, can cause life-threatening serotonin syndrome. Individuals taking antidepressants are at highest risk for this complication. Too much serotonin in the body can lead to a range of symptoms, such as: agitation, confusion, high blood pressure, loss of muscle coordination, and headaches. At higher doses, DMT can cause seizures, respiratory arrest, and coma. DMT could have serious adverse consequences for users with pre-existing psychological problems or a mental illness, such as schizophrenia. Pregnant women should not use Sacraments due to possible negative effects on the fetus.
Liability Agreement and Hold Harmless Provisions
Being fully informed as to risks laid out above and in consideration of the Services, Client shall forever release, indemnify, and hold harmless Church from any and all claims, counterclaims, damages, defenses, setoffs, recoupments, debts, demands, causes of action, suits, obligations, losses, costs, expenses, and liabilities of any nature whatsoever, in law or in equity, whether known or unknown, fixed or contingent, including but not limited to those arising from the Services and Sacraments. Client covenants not to sue Church, or any of Church’s principals, contractors, or agents, and waives any right of recovery, whether known or unknown, that Client may have to bring a claim or a lawsuit against Church for any personal injury, death, damage to personal property or other injury arising from the Services and natural medicines, whether arising from a theory of any tort, including negligence, or any other theory in law or equity. This Agreement shall inure to the benefit of any member of the Church’s family, spouse, heirs, assigns, real property, attorneys and personal representatives. The Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. By signing below, the Client attests that they have fully and truthfully disclosed all relevant medical and mental health conditions and Church assumes no responsibility for any claims or damages caused by the Client’s failure to disclose or misrepresentation of medical or mental health information. In no event shall Church’s liability, if any, exceed the amount paid for the services by the Client.
Confidentiality
This Agreement and the Services provided hereunder are confidential and may not be disclosed by Client to any third party (other than the Client’s immediate family and friends) except as required by any applicable law or valid Court order. Client shall not make social media or other public posts regarding the Services.
Use of Touch
There are two types of “touch” considered during the Services, safety and support. Regarding touch for safety: If there is an issue in which the Church determines that touch is required for your safety, you acknowledge and consent to being touched, e.g., holding your arm to avoid falling, or to provide support to walk to the restroom. Regarding touch for support: If, during the Services, a supportive touch, e.g., placing a hand on your shoulder or forearm, appears that it could be helpful, the Church will offer this supportive touch to you. You may verbally or non-verbally (shake your head yes or no) decline this offer or accept at any time during the Services. You may also change your mind. For example, if you request or prefer supportive touch at one point in the Services, you may decline to do so later. Before the Services, the Church will engage you in a discussion about your preferences for supportive touch during your session, including but not limited the differences between touching for safety and for support, your choice for engaging in supportive touch and your right to change your mind.
Miscellaneous
Mediation/Arbitration. Prior to initiating any action under this Agreement, the Parties agree to engage in mediation to resolve any disputes. For any dispute not resolved by mediation, any remaining dispute, claim, interpretation, controversy, or issues of public policy arising out of relating to this Agreement, including the determination of the scope or applicability of this Section, will be determined exclusively by mandatory binding arbitration held in Denver, Colorado, and will be governed exclusively by the Colorado Revised Arbitration Act, §§ 13-22-201, et seq., C.R.S. (the “CRAA”). The Parties waive (i) any right of removal to the United States federal courts and (ii) any right in the United States federal courts to compel arbitration, to confirm any arbitration award or order, or to seek any aid or assistance of any kind. If either party brings an action to enforce the provisions of this Agreement and is the substantially prevailing party in any action, the substantially prevailing party will be entitled to recover its reasonable attorneys’ fees and expenses incurred in such action.
Medical Treatment. Client hereby consent to receive medical treatment which may be deemed advisable in the event of a medical emergency, injury, accident, and/or illness during the Services.
No Third-Party Beneficiaries. The terms and provisions of this Agreement are intended solely for the benefit of the Parties and their respective successors or permitted assigns, and it is not the intention of the Parties to confer third-party beneficiary rights upon any other Person.
Entire Agreement. This Agreement supersedes all prior discussions and agreements between the Parties and/or their Affiliates with respect to the subject matter hereof and contains the sole and entire agreement between the Parties and their Affiliates with respect to the subject matter hereof.
Waiver. Any term or condition of this Agreement may be waived at any time by the Party that is entitled to the benefit thereof, but no such waiver will be effective unless set forth in a written instrument duly executed by or on behalf of the Party waiving the term or condition. No waiver by any Party of any term or condition of this Agreement, in any one or more instances, will be deemed to be or construed as a waiver of the same or any other term or condition of this Agreement on any future occasion. All remedies, either under this Agreement or by Law, are cumulative and not alternative.
Succession and Assignment. This Agreement is binding upon and will inure to the benefit of the Parties and their successors and assigns. No Party may assign this Agreement or any of its rights, interests, or obligations hereunder.
Governing Law. This Agreement is governed by and construed and enforced in accordance with the laws of the State of Colorado, without giving effect to any conflict or choice of law provision that would result in imposition of another state’s law. THE PARTIES WAIVE ANY DEFENSES BASED UPON INVALIDITY OF CONTRACTS FOR PUBLIC POLICY REASONS AND/OR THE SUBSTANCE OF THE CONTRACT VIOLATING FEDERAL LAW.
Participant acknowledges that he or she has read this Release fully and understands it, including its binding legal consequences, intends to be bound by this Release, and is signing this Release freely and voluntarily.
The information provided in the form below is a complete and accurate statement of the physical and psychological factors which may affect my participation in the Ceremony. I realize that failure to disclose such information now, and failure to provide update of any changes in the future, could result in serious harm to me and fellow participants and I agree to indemnify and hold harmless the facilitator if all relevant information is not disclosed. I also agree to notify the facilitators should there be any change in the information provided or in my health status during this Ceremony and before and during any subsequent Ceremony.