Become a Member

First Name (*)

Last Name (*)

Phone Number(*)

Email (*)

Birthdate (*)

Home City (*)

State (*)
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In Wich ceremony do you want to participate? Retreat – Littleton, New Hampshire - March 14 - March 16Retreat – Amazonia Colombia – Puerto Asís Putumayo - July 24 - August 4
Intake screening form and attestation
YOU MUST BE 100% TRUTHFUL AND ACCURATE IN COMPLETING THIS FORM AS YOUR RESPONSES TO THE FOLLOWING QUESTIONS DETERMINE WHETHER YOU MAY SAFELY PARTICIPATE IN A CEREMONY WITH KAMENTSA INGA CHURCH, THE SOUL OF THE HUMMINBIRD.
* I hereby confirm 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 answers to the foregoing 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 answers to the foregoing screening questions, that such a denial is based on the determination that my exclusion is for the safety and benefit of myself and other ceremonial participants.
* I understand that this screening form is part of Kamentsa Inga Church, The Soul of the Hummingbird Waiver of Liability form.
* I hereby warrant and represent that I am of sound mind and body and it is my belief, I am mentally and physically fit to participate in a ceremony with Kamentsa Inga Church, The Soul of the Hummingbird, notwithstanding its staff's determination as to my fitness to participate.
* I hereby warrant and declare that in spite the fact that I may have physical and/or mental illnesses, I believe that I am fit to participate in a ceremony with Kamentsa Inga Church The Soul of the Hummingbird. For the healing of these.
* I hereby grant the Kamentsa Inga Church, The Soul of the Hummingbird permission to take 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 Kamentsa Inga Church The Soul of the Hummingbird to administer to me their sacred sacrament ayahuasca-yage and the other elements that the church deems necessary for my physical and spiritual healing process.
I hereby grant the Kamentsa Inga Church, The Soul of the Hummingbird permission to take my photograph, video, or other digital media (“photo”) in any of its publications, including web-based publications, without payment or other consideration. YesNo
[group G-Y-N8] * Refrain from participating in photographic shots that may become material for our online media.[/group]
In addition to allowing us to evaluate your participation for safety purposes, this form also allows us to get a better understanding of what your intention(s) is in joining us for a sacred ceremony.
*Do you have a history of, or currently suffer from any serious health condition or mental illness?—Please choose an option—YesNo
[group G-Y-N] Write them below:
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*Are you currently or have you been taking (in the past twelve (12) months) any type of medications?—Please choose an option—YesNo
[group G-Y-N2] Write them below:
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*Have you ever consumed natural entheogenic/psychoactive medicines before?—Please choose an option—YesNo
[group G-Y-N3] Write them below:
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*Do you have any experience consuming natural entheogens in a sacred or ceremonial context?—Please choose an option—YesNo
[group G-Y-N4] Write them below:
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*Have you had any medical procedures or surgeries in the past 2 months?—Please choose an option—YesNo
[group G-Y-N5] Write them below:
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*Are you currently pregnant?
YesNo
Good faith consent: I accept the terms and conditions of this Waiver
*How did you hear about us?
—Please choose an option—Google SearchSocial MediaFriendFamilyOther
[group G-Y-N6] Who: [/group]
[group G-Y-N7] Write below: [/group]
Provide us with an emergency contact. Be sure to let this person know you are using them as a contact for the purposes of the Ceremony.
*Emergency contact First Name and Last Name:

*Emergency Contact Phone Number