Email * To which gender identity to you most identify? * Male Female Transgender Female Transgender Male Gender Variant/Non-conforming Two Spirit Person Have you worked with any medicines before? *
Examples: Ayahuasca, Huachuma (San Pedro), Peyote, Psilocybin (Magic Mushrooms), Cannabis, MDMA, LSD, 5-MEO DMT (including Bufo), Mescaline, Ketamine, etc.
Which of the following have you worked with?
Check all that apply
Please tell us about your experience(s) working with these medicines? *
Things you may include: when you worked with the medicine; with whom; your experience(s)/impression(s).
Have you ever had an adverse reaction to any medicine? * Please tell us about any adverse reactions you experienced? * Please tell us about what you do in the world, whether for work or as a passion. *
We are particularly interested in offering this retreat for those who hold space in some capacity, and would love to know about this aspect of your life.
What do you hope to receive from this experience?
If you would like to share, please do.
What kind of support network do you have for after this retreat?
We will be holding a post-retreat container, but we also want to ensure that everyone has a support network whether it's in community, family, integration, therapy, etc.
What is your general state of health? *
Please let us know about anything you have been aware of with regard to your health that isn't fully resolved.
Do you feel physically fit enough to experience a possibly challenging healing experience that involves an all-day hike at high elevations? *
In addition to being fit to participate in plant medicine ceremonies, please also consider that these ceremonies are all day hikes at high elevation (above 9,000 feet).
Have you ever experienced the symptoms of or been diagnosed with any of the following? *
The use of diagnostic names does not serve in the work we do with people, so we do not fixate on these diagnoses. We are only using these terms in this questionnaire for simplicity as many people have received these diagnosis from others in the past, and they can be useful shorthands for describing a constellation of symptoms. Because of the nature of this retreat and our participation in plant medicine ceremonies, these questions are helpful so that we can give you the best advice on how to properly prepare.
Please explain your experience(s) with the above. * What are the medications and supplements, prescription and non-prescription alike, that you have been taking recently (including vaccines)? *
Please list all supplements you take regularly as well as other medications.
Have you had any surgeries in the previous six months? * Do you have a current passport for entry into Peru? *
U.S. Passport holders do not need a visa to enter Peru. Please be sure that the expiration date is at least 6-months after the retreat as you can be denied entry. If your passport is going to expire this year it would be prudent to renew it prior to the retreat.
Please describe briefly any prior or concurrent self-healing work that you are engaged in or that you engaged in during the past. *
For instance, if you have been in therapy please tell us a little about that (such what type of therapies helped or didn't help), or if you have experiences with yoga, meditation, breath work, dance, or other relevant practices.
Will you commit to the preparation prescribed for ceremony? *
Preparing for ceremony may include eating a modified diet, eliminating certain substances, ceasing the use of certain commercial products and other modifications to one's lifestyle. Preparation may also include eliminating one's diet of media, news, social media and other external sources of information for a period of time. You will be provided with detailed preparation information so that you can best ready yourself for the ceremonies. If you know in advance you will be unable to commit to such preparations, please answer "No" below. If you believe you can, or if you have the inner will to commit to such preparations, please answer "Yes."
Is there anything else you would like to let us know about? * What else would you like to tell us about your interest in attending this retreat?
Feel free to use this space as you see fit. We are cultivating a close-knit-group and would love to be able to learn more about your interest.
Retreat Release and Agreement for Peru Retreat
Date of Retreat: August 3-13, 2023
I (hereafter referred to as "Participant"), hereby acknowledge and agree to the following terms and conditions in consideration for the opportunity to participate in the Peru Retreat (hereafter referred to as "Retreat") organized by Hamid Jabbar PLC and it's owner, Hamid Jabbar, and Sara Gensmer, (hereafter collectively referred to as "Organizer").
Risk Acknowledgement. Participant acknowledges that participating in the Retreat involves inherent risks, including but not limited to risks of accidents, injuries, illness, death, or loss or damage to personal property, that may be caused by the actions or inactions of other participants, third parties, or the Organizer, or by other factors beyond the control of the Organizer. Participant understands that such risks may be heightened by travel to foreign countries, including risks related to acts of government or war.
Release and Waiver of Liability. Participant hereby releases and forever discharges the Organizer and its owners, officers, directors, employees, agents, and affiliates (collectively, "Releasees"), from any and all claims, demands, causes of action, damages, losses, liabilities, or expenses (including attorneys' fees and costs) that may arise out of or in connection with Participant's participation in the Retreat, including but not limited to any claims for personal injury, illness, or death, or for loss or damage to personal property. This release and waiver of liability applies regardless of the cause of such claims or losses, including negligence or other fault of any of the Releasees.
Indemnification. Participant agrees to indemnify and hold harmless the Releasees from any and all liabilities, damages, costs, or expenses (including attorneys' fees and costs) that may arise out of or in connection with Participant's participation in the Retreat, including but not limited to any claims brought by third parties related to Participant's actions or omissions. This includes, Participant's damage to property.
Medical and Travel Insurance. Participant acknowledges and understands that he or she is solely responsible for obtaining and maintaining adequate medical and travel insurance for the duration of the Retreat. Participant agrees that the Organizer is not responsible for any medical expenses or other costs incurred by Participant in connection with the Retreat.
Retreat payments and deposits. Participant acknowledges that all deposits and payments are non-refundable except in the event of cancellation of the Retreat by Organizer. In the event Participant cancels after submitting a deposit and/or payments, Organizer will refund Participant's payments only if Organizer is able to replace Participant's spot with another qualified participant. Organizer does retain the right to cancel the Retreat and, if Organizer exercises this right, Organizer will refund all monies paid by Participant.
Governing Law. This agreement shall be governed by and construed in accordance with the laws of the State of Arizona, without giving effect to any choice of law or conflict of law provisions thereof.
Entire Agreement. This agreement constitutes the entire agreement between Participant and the Organizer and supersedes all prior negotiations, understandings, and agreements between the parties with respect to the subject matter hereof.
By clicking the "I Agree" button below, I certify that I have read this Retreat Release and Agreement, fully understand its terms, understand that I have given up substantial rights by clicking the "I Agree" button, and have clicked the "I Agree" button freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law, and agreement to all other terms and conditions. I agree to the terms of the Retreat Release and Agreement.