Private Ceremony

Inner Peace Wellness Center serves one sacrament: 5-MeO-DMT (Bufo Alvarius). For health and safety reasons you cannot attend if you have taken SSRIs within 2 weeks, recreational drugs or any medication within 3–4 days, or supplements within 24 hours prior to ceremony. By checking below I affirm that ALL of the following are true: • I am over the age of 21. • I do not have a history of psychosis and/or schizophrenia. • I have not been diagnosed with a personality disorder. • I do not have an active medicated diagnosis or history of bipolar disorder. • I do not have a history of seizures or a diagnosis of epilepsy. • I am not currently experiencing anorexia and/or bulimia. • I have not experienced a stroke or embolism. • I do not have severe asthma or emphysema. • I do not have a known cardiac illness. • I do not have a history of severe uncontrolled high blood pressure. • I do not have a history of schizoaffective disorder. • I do not have a history of severe psychiatric instability. • I am not currently taking medications that may be contraindicated, including any that interact with MAOI-containing preparations. • I am not in my first trimester of pregnancy. If any of the above is NOT true, do not check this box — contact Kaitlyn first so we can discuss your circumstances.

Inner Peace Wellness Center and its representatives are not licensed medical professionals and do not provide medical advice, diagnosis, treatment, or healthcare services. Any information shared before, during, or after ceremony is offered solely for educational, spiritual, and informational purposes and should not be interpreted as medical advice. Participants should never discontinue, adjust, or modify prescribed medications without first consulting their prescribing physician or qualified healthcare provider. Participation in ceremony is not intended to diagnose, treat, cure, or prevent any physical or mental health condition. By checking below I acknowledge that: • I have read and understand this medical disclaimer. • I understand no medical advice or healthcare service is being provided. • I agree to consult my physician regarding my medications and medical conditions. • I certify the information I have provided is accurate and complete. • I understand that withholding relevant medical or psychological information may place me at risk. • I understand participation is voluntary and that completing this form does not guarantee acceptance into a ceremony, and that participation may be postponed, rescheduled or declined if safety concerns arise.

Please read carefully. By checking below you acknowledge that you have read, understood, and voluntarily agree to all terms contained here. ELIGIBILITY. I certify that I am at least twenty-one (21) years of age and legally capable of entering into this agreement. VOLUNTARY PARTICIPATION. My participation in any ceremony, event, retreat, training, gathering or sacramental experience is completely voluntary. I may decline participation at any time prior to receiving any sacrament, and I am not being coerced, pressured or influenced by anyone. SPIRITUAL NATURE. Inner Peace Wellness Center is a religious and spiritual organization and the sacrament offered — 5-MeO-DMT (Bufo Alvarius) — is provided solely within a spiritual, religious, ceremonial, educational and personal-growth context. No particular outcome, healing, insight, breakthrough, transformation or benefit is guaranteed. Spiritual experiences are subjective and vary significantly between participants. DISCLOSURE OF HEALTH INFORMATION. I certify that all information provided in my intake and screening is truthful, complete and accurate to the best of my knowledge. I understand that withholding information regarding medical conditions, psychiatric conditions, medications, supplements, substance use or personal history may increase the risk of adverse outcomes. I agree to notify Inner Peace Wellness Center immediately of any change to my physical health, mental health, medications, supplements or circumstances prior to participation. ASSUMPTION OF RISK. I understand that participation may involve substantial, serious and unforeseeable risks, including but not limited to: intense emotional and psychological experiences; altered states of consciousness; physical discomfort; elevated blood pressure; changes in heart rate; anxiety, fear, panic, confusion; dizziness or loss of balance; nausea and vomiting; emotional release; recollection of traumatic memories; psychological distress; spiritual crisis; physical injury or falls; aggravation of known or unknown medical conditions; unexpected reactions; serious injury; permanent disability; and death. I acknowledge that no screening process can eliminate all risks, and I knowingly and voluntarily assume all known and unknown risks associated with my participation. EMERGENCY MEDICAL CARE. In an emergency I authorize Inner Peace Wellness Center and its representatives to seek emergency medical assistance on my behalf if deemed necessary. I understand I am solely responsible for all costs associated with emergency treatment, transportation, hospitalization, physician services and related expenses. RELEASE OF LIABILITY. To the fullest extent permitted by law, I voluntarily release, waive, discharge and hold harmless Inner Peace Wellness Center, Kaitlyn Pisano, and its ministers, facilitators, volunteers, contractors, employees, officers, directors, agents, representatives, successors and assigns, together with the owner of any property where a ceremony, event, training, retreat or gathering is held and any landlord, property manager, host or venue provider, from any and all claims, demands, causes of action, damages, losses, injuries, liabilities, costs, expenses, attorney fees or legal actions of any kind arising from or related to my participation, including claims arising from negligence, to the maximum extent permitted under applicable law. COVENANT NOT TO SUE. I agree that I shall not file, initiate, participate in or maintain any lawsuit, claim, complaint, arbitration, administrative action or legal proceeding against any released party for any claim arising out of or related to my participation. I understand this is a material condition of my participation. INDEMNIFICATION. I agree to defend, indemnify and hold harmless all released parties from any claims, damages, liabilities, losses, attorney fees or expenses arising from my actions, conduct, participation, omissions or breach of this agreement. REFUND POLICY. I understand that all registrations, donations, contributions, tuition, retreat payments, deposits and event fees are subject to Inner Peace Wellness Center's refund, cancellation and rescheduling policies. ACKNOWLEDGEMENT. I am at least 21 years of age. I have carefully read this entire agreement and fully understand its contents. I understand that I am waiving important legal rights. I voluntarily assume all risks associated with participation, release the parties above from liability, and agree not to sue. I sign this agreement freely, voluntarily and without coercion.