Portland, OR: Amazonian Indigenous Dreamwork and Tea

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1 Welcome

2 Contribution

	$30.00 to $60.00 – Sliding Scale Conbribution (Includes Course Work & Tea Ceremony)
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3 People in your group

Guest 1		First Name* Last Name* Email* Gender
Guest 1		First Name* Last Name* Email* Gender

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4 Participant Info

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URL link to your Facebook Page *	This is used so we can create a facebook group for participants of this program.
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Birth Date *
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Dietary Restrictions? *
Allergies? *	Food, medicine, specific insects, etc.? List "none" if you have no allergies.
Please list all supplements & pharmaceutical mediations. *	List all by name, dosage and reason for taking. State "none" if you don't take medications.
Birth Control (IUD or pills)? *	Please share the details of your birth control method. If not applicable state "none".
Additional Comments or Special Needs?	Any additional health & care information not listed above that we should be aware of.
How did you hear about this program and the Paititi Institute? *
Email newsletter	Yes, please sign me up for the email newsletter!We do not share our list
Terms, Conditions, Release of Liability & Assumption of Risk *	I accept the terms and conditions.Read Terms and Conditions Here
Payments do not include the cost of plant medicines. *	I understand that payments made through Retreat Guru do not include the cost of: plant medicine, psychedelics or similar products. There will be no additional charges for this retreat.Supplementary Products Exclusion: Participants acknowledge and agree that these Fees presented and payable pertain solely to Services and Offerings, and will not include the cost of any plant-medicines or similar products (collectively, "Supplementary Products") which may be provided, offered, or distributed by a Commercial User, or any other party, in connection with Services or Offerings. Retreat Guru shall bear no responsibility or liability in connection with any provision, offering, or distribution of Supplementary Products, and is not a party thereto. All capitalized terms used herein shall carry the same meaning as assigned to them in Retreat Guru's Terms of Service.

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5 Security Check

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6 Contribution

3.9% Credit card merchant fee	$0

Sub Total	$0

Donations	$0

Taxes	$0

Deposit	$0

Due Now	$0 $0