Membership Form Application date Previous Next First Name: Last Name: Phone Number: E-Mail: Where you live (City and State) Ceremony to be attended: Ceremony: Previous Next By digitally signing this form, I authorize Kamentsa Inga Church, The Soul of the Hummingbird, to take my photograph, video or other digital media (“photo”) in any of its publications, including web-based publications, without payment or other consideration. SíNo y digitally signing this form, that I understand the need and importance to answer the following questions truthfully, as accurately as possible and to the best of my knowledge and hability. I understand that my responses to the above screening questions determine my eligibility to participate in sacred ceremonies with Kamentsa Inga Church, The Soul of the Hummingbird; and if I am denied participation in a ceremony due to my responses to the above screening questions, such denial is based on a determination that my exclusion is for the safety and benefit of myself and other ceremony participants. I understand that this membership form is an integral part of Kamentsa Inga Church, The Soul of the Hummingbird Waiver of Liability form. By digitally signing this form, I represent and warrant that I am of sound mind and body and believe that I am mentally and physically fit to participate in a ceremony with Kamentsa Inga Church, The Soul of the Hummingbird, notwithstanding the determination of its staff regarding my fitness to participate. By digitally signing this form, declare that in spite the fact that I may have physical and/or mental illnesses, I believe that I am fit normasly to participate in a ceremony with Kamentsa Inga Church The Soul of the Hummingbird. For the healing of these. By digitally signing this form, I grant Kamentsa Inga Church, The Soul of the Hummingbird, permission to take and publish my photograph, video or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I authorize, under my sole responsibility and at my own risk and expense, Kamentsa Inga Church The Soul of the Hummingbird to administer to me its sacred sacrament ayahuasca-yage and the other elements that the church considers necessary for my physical and spiritual healing process. Previous Next Do you have a history of or currently suffer from any serious mental illness? If the answer is yes, briefly explain. Sí (Explain)No Are you currently or have you been taking (in the past twelve (2) months) any type of medications? Sí (Explain-What the medications)No Have you ever consumed natural entheogens/psychoactives, such as mushrooms (fungi), cannabis, peyote, San pedro, ayahuasca yage, among others? If your answer is yes, say which of these Sí (Explain-What the medications)No Do you have any experience consuming natural entheogens in a sacred or ceremonial context? Sí (Explain-What the medications)No Have you had any medical or surgical procedures in the last 2 months? If your answer is yes, explain your current health status. Sí (Explain-What the medications)No When you submit this form, you are implicitly granting good faith, broad and sufficient consent, full release from liability, and I declare under oath that: I accept the terms and conditions of this release. Previous Next For Women Only, Are you currently pregnant? If your answer is yes, you will not be able to participate in any of our ceremonies while you maintain this natural physical state. NoSi Through which medium did you find us? Social MediaFriends or familyPresentations at holistic centers or fairs.Otros Referred by: First Name: Last Name: Emergency Contact : First Name: Last Name: Upload Your Health History: Supports PDF Only Previous Next
