Ayahuasca Registration Form

Name *

First

Last

Email *

Phone Number *

Terms & Conditions *

I Agree to the Terms & Conditions

I attest that all information is accurate and accept full legal and personal liability for joining this retreat, protecting John Driggs and The Space of Possibility from all legal liability.

Non-Refundable Deposit *

I Understand that my Deposit is Non-Refundable

I understand that $1,300 of my payment will be considered a non-refundable deposit once my registration is confirmed.

Official Language *

My English is Proficient

I understand that English is the official language of the retreat and all participants are required to possess proficient communications skills.

Phone Number &

Contraindications *

I Attest

I attest that none of the applicants in this form have been diagnosed with Bipolar condition (I or II), Schizophrenia, Schizoaffective Disorder, Borderline Personality, Psychosis or Epilepsy.