Legal Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Meals *

Vegetarian

Non-Vegetarian

Waiver *

I am over 21 years of age, and will be responsible for my own mental health.

*

I understand that I am an invited guest and that I will comply with the instructions of event coordinators with regard to my personal health and safety.

*

I have been fully informed and understand that I will be ingesting legal plant medicine. I agree that I will not ingest alcohol or any additional substances in combination with this either prior to or for the duration of the workshop.

Indemnity *

I will hold harmless, Earth Traditions, The Dekoven Center, Angie Buchanan, Drake Spaeth, Emporium Black or Seamus Black for any illness, injury, or undesired consequences resulting from any part of this event.