Peru Retreat Intake Participant Agreement & Informed Consent Form

Participant Agreement & Informed Consent

Retreat Name: Plant Medicine Retreat at Tambo Ilusion

Location: Tarapoto Peru

Dates: June 2-12, 2026

Facilitator / Organizer: Mary Newstrom

This agreement is offered as a container of clarity, care, and mutual respect—so that we may enter this retreat experience with awareness, choice, and personal responsibility, in service of safety, presence, and shared intention.

Entering the Journey: Voluntary Participation & Awareness of Risk

I acknowledge that I am choosing to participate in this retreat, which may include international travel, walking or hiking, time at altitude, spiritual or ceremonial practices, group experiences, and immersion in unfamiliar environments. I understand that all journeys carry inherent risks, including physical injury, illness, emotional or psychological responses, travel-related incidents, and unforeseen events. I knowingly and willingly assume these risks.

Care of Self: Health & Personal Responsibility

I affirm that I am physically, mentally, and emotionally able to participate. I take responsibility for consulting qualified healthcare professionals as needed and for sharing any relevant medical or psychological conditions, medications, or limitations. I understand that the facilitator is not providing medical or mental health care.

Mutual Respect: Release of Liability & Responsibility

To the fullest extent permitted by law, I release, waive, and hold harmless Mary Newstrom, co-facilitators, guides, assistants, hosts, and affiliates from any claims or liability arising from my participation, including injury, illness, emotional distress, loss, or death.

I agree to take responsibility for my actions and to indemnify and hold harmless the released parties from any claims arising from my conduct during the retreat.

The Larger Web: Travel, Third Parties & Insurance

I understand that the facilitator is not responsible for the actions or omissions of airlines, transportation providers, lodging facilities, or other third-party services. I am responsible for securing my own health, travel, and evacuation insurance.

Sacred Practice: Spiritual & Ceremonial Experiences (If Applicable)

I understand that spiritual or shamanic practices are experiential and may evoke emotional, energetic, or psychological responses. Participation is always voluntary. I accept full responsibility for my experience and integration.

Plant Medicine Acknowledgment (If Applicable)

If traditional plant-based ceremonies are offered, I understand that participation is optional and a personal choice. I accept full responsibility for my decision to participate or not and release the facilitator from any related liability.

Witnessing the Journey: Photo & Media Consent

I give permission for photographs, video, or audio recordings taken during the retreat to be used for educational or promotional purposes. No compensation is expected or provided.

Clarity of Commitment: Cancellation & Refund Policy

I acknowledge that I have read, understand, and agree to the retreat’s cancellation and refund policy as provided separately.

Acknowledgment & Signature

I have read this agreement carefully, understand its contents, and sign it voluntarily.

Participant Name

Email(Required)

Participant Address(Required)

Participant Phone

Are you on Whats App?

Signature (Electronic is OK)

Date

Emergency Contact

Name

Phone

Are they on Whats App?

Travel Details (For Coordination & Support)

To support smooth arrivals, departures, and group coordination, please share your travel details below.

Airline(s)

Flight out of Tarapoto, Peru (TPP):

Arrival Date

Flight Number

Arrival Time

Flight into Tarapoto, Peru (TPP):

Departure Date

Flight Number

Departure Time

If your travel plans are not yet finalized, please share details once confirmed.

Participant Health & Care Awareness (Confidential)

In the spirit of care, safety, and respect for each person’s experience, we invite you to share any information you feel is important for us to be aware of during the retreat. This information will be kept confidential and used only to support your well-being.

Medications you will be on during the retreat (including dosage, if relevant):

Medical conditions or health considerations we should be aware of (physical, emotional, or psychological):

Mobility considerations (e.g., comfort sitting or lying on the floor, ability to move from floor to standing multiple times during ceremony, walking on uneven terrain, use of supports):

Food allergies or dietary restrictions:

Anything else you feel called to share that would help us support you during the retreat:

Thank you for sharing this information