Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Date of Birth
Emergency Contact Name
Phone
(###)
###
####
How did you hear about Eco Tribal Immersions?
Have you ever participated in a tribal immersion or similar experience?
Why are you interested in participating in a tribal immersion with Eco Tribal Immersions?
What are your intentions for participating in this experience (spiritual, personal growth, healing, etc.)?
Have you ever participated in humanitarian work before?
Why do you feel that you can be a good participant in this type of tribal immersion?
1. Have you ever worked with any plant medicines?
If yes, please list the plant medicines you have worked with:
2. If you have worked with plant medicines, how was the experience and when did it occur?
Please describe the most notable effects, insights, or transformations you experienced:
3. Have you worked with Kambo before?
If yes, please list the plant medicines you have worked with:
1. Where do you currently stand in your spiritual development or practice?
2. What types of inner work have you been focusing on?
3. What are your intentions for joining this tribal immersion experience?
4. How do you feel this type of tribal immersion can support your personal or spiritual growth?
5. Do you have any specific areas of personal or spiritual development you would like to focus on during this immersion?
1. Do you have any autoimmune diseases or conditions?
2. Do you have any history of endocrine disorders, such as Addison's Disease or other hormone imbalances?
3. Do you currently have any health problems?
4. Have you suffered from any significant health problems in the past or have you had any surgeries?
5. Do you have any history of mental health issues?
(e.g., depression, anxiety, PTSD)
6. Do you take any prescribed medications, supplements, or herbs?
7. Are you currently taking any medications or treatments for chronic conditions?
(e.g., high blood pressure, diabetes, etc.)
8. Do you have any allergies to medications, foods, or other substances?
9. Are you currently pregnant or breastfeeding?
10. Have you ever been diagnosed with or treated for any of the following conditions?
(Check all that apply)
1. On average, how many glasses of water do you drink per day?
2. Do you engage in regular physical exercise or activities?
3. Do you currently follow a particular diet or nutrition plan?
4. Do you have any habits that may impact your health or well-being?
(e.g., smoking, alcohol consumption, etc.)
I acknowledge that I have answered all questions truthfully and to the best of my knowledge. I understand that failure to disclose important health information could result in complications during my participation in Eco Tribal Immersions.
I consent to share my health information with Eco Tribal Immersions for the purpose of creating a safe immersions.
I also acknowledge that it is my responsibility to inform Eco Tribal Immersions of any health changes that may affect my participation.
