BUFO HEALING SANCTUARY Intake, and Waiver Form

PLEASE 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 FACILITATED BY BUFO HEALING SANCTUARY .YOU MAY BECOME A MEMBER OF BUFO HEALING SANCTUARY EVEN IF YOU ARE NOT ABLE TO PARITICPATE IN CEREMONY. PLEASE SIGN BELOW KNOWING YOU HAVE ANSWERED ALL THE QUESTIONS IN HONESTY. Thank you for allowing us to evaluate your participation for safety purposes. We are wanting to get a better understanding of who you are, what your intentions are and how we can give you the best integration services possible.

We would like to get to know YOU!

What brought you to Bufo Alvarius and to Bufo Healing Sanctuary?

Do you have any past or current physical or mental health condition? (If yes, please explain)

In the past twelve (12) months have you taken or are you currently taking any type of medications, vitamins, or supplements?

Are you currently detoxing from heavy metals and parasites? If not, would you like to learn about detoxing?

Have you ever consumed natural entheogenic/psychoactive medicines before. If yes, what were they and what were the effects?

Emergency contact name, phone number, & relationship.

Are you currently under the care of a family physician, mental health professional or any other health professional?

Have you been diagnosed by a medical professional with any of the following conditions?

Do you have any allergies? (e.g.: foods, medications, pollens/molds, chemicals, animal hair, etc.)

Have you ever been diagnosed with a mental health disorder (e.g., depression, bipolar disorder, schizophrenia/schizoaffective disorder/ paranoia/psychosis, eating disorders, obsessive compulsive disorder, suicidal thoughts/actions, self-harm thoughts or actions, impulsivities, history of violence, anxiety/panic attacks, ADHD/PTSD, any personality disorder, etc.)?

Which of these substances do you currently use or have used in the past?

What age did you start first use and age at last use of any of the substances above. (Example: Alcohol - 13, 35)

Have you ever had a spiritually transformative experience (STE) such as an out of body experience, near death experience (NDE), kundalini awakening, any Clairs, mystical or spiritual experience (not induced by a psychoactive substance? If so, please explain...

PIease type your name and date below. I hereby confirm that I understand the importance of answering the foregoing questions truthfully and to the best of my knowledge and ability.  This understanding is reflected in my initials at the top of this document. Therefore, I hereby represent that all answers to the foregoing screening questions are 100% truthful and accurate.  I further understand that my answers to the foregoing screening questions determine my eligibility to participate in BUFO HEALING SANCTUARY scared ceremonies; and if I am denied participation in an BUFO HEALING SANCTUARY ceremony, due to my answers to the foregoing screening questions, that such a denial is based on BUFO HEALING SANCTUARY determination that my exclusion is for the safety and benefit of myself and other ceremonial participants. I understand that this screening form is attached to and made part of Bufo Healing Sanctuary 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 an Bufo Healing Sanctuary sacred ceremony, notwithstanding its staff's determination as to my fitness to participate.

Please initial below: Waiver of Liability and Releasein Consideration of. Please initial below the risk of injury that exists while participating in the Sacred Ceremony facilitated by Bufo Healing Sanctuary (hereinafter the “Activity”); and,IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; andI HEREBY release and forever discharge Power of Bufo Healing Sanctuary, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively, “Releasees”), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity. I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN/SUFFERING, PHYSICAL OR MENTAL ILLNESS, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH.  I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS’ NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S).  NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY. I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs.I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees.  In the event that I should require medical care or treatment, I authorize Bufo Healing Sanctuary to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AED’s, emergency medical transport, and sharing of all medical information with medical personnel.  I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment.  I am aware and understand that I should carry my own health insurance. I FURTHER ACKNOWLEDGE that this activity may involve a test of a person’s physical and mental limits and may carry with it the potential for death or serious injury.  I agree not to participate in the Activity unless I am medically able and I agree to abide by the decision of the Bufo Healing Sanctuary official or agent, regarding my approval to participate in the activity. I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.  I EXPRESSLY AGREE TO RELEASE AND DISCHARGE BUFO HEALING SANCTUARY AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE MIGHT HAVE TO BRING A LEGAL ACTION AGAINST BUFO HEALING SANCTUARY FOR PERSONAL INJURY. I FURTHER REPRESENT that I have been provided information regarding the contraindication of natural entheogens with certain medications, including but not limited to SSRI’s and MAOI's.  I represent that I have read and fully understand the information that was provided to me.

I represent that I am not currently taking any of the medications listed that are contraindicated with natural entheogenic substances, such as those to be consumed as part of the Activity, as defined herein.

PLEASE INITIAL BELOW: I FURTHER REPRESENT that I have been provided information regarding the dangers associated with consuming natural entheogenic substances while suffering from certain medical conditions, both physical, and/or mental/psychological in nature.  I represent that I have read and fully understand the information that was provided to me.  I represent that I am not currently suffering from any of the medical conditions listed.

I FURTHER REPRESENT THAT I HAVE BEEN ABSOLUTELY TRUTHFUL AND HONEST IN DISCLOSING MY CURRENT MEDICATIONS AND PRIOR AND CURRENT MEDICAL HISTORY AND I UNDERSTAND THAT NOT BEING TRUTHFUL AND HONEST REGARDING SAID ITEMS COULD RESULT IN MY PHYSCIAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH AS A REUSULT OF MY PARTICIPATION IN THE ACTIVITY. I FURTHER REPRESENT that I will follow instructions given by the facilitators of the Activity, will not leave the ceremony space until the conclusion of the Activity, and will not disclose the nature of the Activity or the participants in the Activity to any third parties. I FURTHER REPRESENT that I intend to participate in the Activity with the purest of intention of heart, promoting the well-being of all participants. I FURTHER REPRESENT that I intend to participate in the Activity with the purest of intention of heart, promoting the well-being of all participants. To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Bufo Healing Sanctuary, its agents, and employees. I agree that this Release shall be governed for all purposes by TEXAS law, without regard to any conflict of law principles.  This Release supersedes any and all previous oral or written promises or other agreements. In the event that any damage to equipment or facilities occurs as a result of my or my family’s or my agent’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions or neglect or recklessness. THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.THIS AGREEMENT was entered into at arm’s length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength.  Both Participant and Bufo Healing Sanctuary agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for this it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect.  If a court should find that any provision of this agreement to be invalid and unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT, I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY.  I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL. I ALSO UNDERSTAND THAT BY SIGNING THIS FORM, I AGREE TO BECOME A MEMBER OF BUFO HEALING SANCTUARY.

I release the use of all photos taken of me to be used for promotional use or any other use determined by Bufo Healing Sanctuary. If you are not comfortable with your photos being in the eye of the public, please mark no.