Hello

Please fill out the form below so that we can assure you of the best possible guidance along this path of self discovery. Please fill this out by enrollment.

Grandfather Wellness Assessment Form

The wellness assessment form gives us the opportunity to get to know you better as a person and helps us to make any necessary adjustments or recommendations with a maximum benefit to you.

Health Declaration

Please fill out the following form
in order to participate in our activity.

No marijuana, hape, drugs or other plant medicines allowed whilst on San Pedro, or on property .If brought or used, you will be asked to leave. Using them with San Pedro could result in bad issues.

Your experiences are private. Please keep them private, no Facebook sharing. Thank you

Advise us if you have suicidal thoughts so that we can help you. Don’t suffer in silence.

Respect your guides decisions, we want the best for you and have many years experience.

Do you have any further relevant info regarding health or emotional issues that your guide should be aware of, If yes, please specify.

I am aware that the ingestion of San Pedro is undertaken entirely at my own responsibility and risk. I absolutely and irrevocably release Andrew Spence, Tracy Ray and Lesley Myburgh, assistants and hosts from any claim, legal or otherwise, from accidents, injuries or outcomes, that may occur as a result of my participation and action in the San Pedro Ceremony.

First name

Last name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury? Have you had surgery within the last 9 months?

Yes

If you answered yes to any question, please specify the ilnness & elaborate

Signed

I declare that the info I’ve provided is accurate & complete & agree to the terms outlined above. All disclosures mentioned above are treated as private & confidential.

Thanks for submitting!