Application

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* These fields are required

1 Welcome

2 People in your group

3 Participant Info

Name you prefer to be called
Phone Number *
Can we leave voicemails on this number? *	Yes No
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Birth Date *
Gender *
Emergency Contact Name *	Please share an emergency contact that the MycoMeditations team has permission to correspond with openly, if necessary. Exclude anyone attending the retreat with you.
Emergency Contact Relationship *
Emergency Contact Email *
Emergency Contact Phone *	Please ensure that our staff can leave a voicemail on this phone number.
What made you interested in psilocybin-assisted therapy? *
What is your goal for the retreat? *
Have you ever used psychedelics or plant medicines before? *	Yes No
Please share when you had your experience(s) and the psychedelic(s) consumed *
Please check all boxes that apply to the outcomes of experience: *	Healing from Trauma Emotional Processing Personal Growth & Self Discovery Creativity & Problem Solving Increased Empathy & Connection Mystical Experience Euphoria Emotional Dysregulation Depersonalization Dissociation Paranoia Existential Crisis Prolonged Psychosis Suicidal Thinking Challenges with Integration Catharsis

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4 Health & Background

Please know that certain responses or past medical events may require follow-up or a letter from your doctor to be submitted before approval to join MycoMeditations.

Are you willing to taper off all types of antidepressants, benzodiazepines, sedatives, sleep aids, mood stabilizers, and antipsychotics with the help of your prescribing physician, in order to be medication-free at least 4 weeks* prior to your retreat? *	Yes No Unsure Please note that tapering off of these medications is a requirement to join a MycoMeditations retreat. A list of all medications to be tapered off will be sent to you following your application's approval. *Certain medications or situations may require additional time to taper off appropriately.
Research has shown that certain medications can impact psilocybin experiences. Are you currently taking any of the following classifications of medications? (Check all that apply) *	Stimulant medications (Adderall, Strattera, Ritalin, etc.) GLP-1’s (Ozempic, Wegovey, etc.) Melatonin Antacids N/A
Have you ever participated in mental health therapy or clinical counseling? *	Yes No
Please list dates and your treatment experience: *
Please check all boxes that apply to your therapeutic experiences: *	Symptom Reduction Emotional Regulation Increased Self-Awareness & Insight Stress Relief Development of Healthy Coping Mechanisms Improvement of Physical Symptoms Relief from Physical Pain Behavioral Changes Enhanced Problem-Solving & Decision-Making Skills Setting Healthy Boundaries Reduced Feelings of Isolation Empathy & Connection Healing From Past Trauma Improved Quality of LIfe Temporary Feelings of Vulnerability Experiencing Negative Memories Temporary Increase in Emotional Distress
Has a Medical or Mental Health Professional ever discussed or diagnosed you with any of the following? (Check all that apply) *	Schizophrenia Spectrum Disorders Schizoaffective Disorder Psychosis or Psychotic Episodes Substance-Induced Psychosis Bipolar Disorder (I & II) Borderline or Narcissistic Personality Disorder Oppositional Defiance Disorder N/A
Has a Medical or Mental Health Professional ever discussed or diagnosed one of your immediate family members with any of the following? (Check all that apply) *	Schizophrenia Spectrum Disorders Schizoaffective Disorder Psychosis or Psychotic Episodes Substance-Induced Psychosis Bipolar Disorder (I & II) N/A
Has a Medical Professional ever diagnosed you with or discussed any of the following with you? (Check all that apply) *	High Blood Pressure Irregular Heartbeat Congestive Heart Failure Valvular Heart Disease Heart Attack Aneurysm Stroke Liver Impairment Kidney Impairment Seizure Disorder Epilepsy Cancer N/A
When was this diagnosed? *
How is this condition being managed or controlled? (Check all that apply) *	Medication Surgery Diet/Exercise Resolved N/A
Is your high blood pressure currently under control? *	Yes No
How long has your high blood pressure been controlled or managed successfully? *
What is your resting blood pressure? *
Do you have a history of ventricular tachycardia? *	Yes No
Do you have premature ventricular contractions? *	Yes No
Please share your burden percentage from having premature ventricular contractions *
Do you have atrial fibrillation that is rate-controlled? *	Yes No
What is your resting heart rate? *
Can you walk more than 6 minutes (or 400m) without becoming out of breath? *	Yes No
Do you have any symptoms because of congestive heart failure? *	Yes No
Do you know the percentage from any ejection fraction testing you've done? *	Yes No
What was the percentage of your last ejection fraction test? *
Do you have any valve issues, such as regurgitation (leaky valve) or stenosis (obstructed valve)? *	Yes No
Have you had an echocardiogram for valvular heart disease? *	Yes No
According to your doctor, what was the severity of the results in the echocardiogram? *
When did your heart attack(s) occur? *
Have you had any procedures (bypasses or stents) within the last 6 months? *	Yes No
Have you experienced any chest pain within the last 6 months after moderate exertion? *	Yes No
Have you failed any exertion tests in the last 6 months? *	Yes No
What type of aneurysm do you have? *	Abdominal Thoracic Cerebral
What is the size of the aneurysm (in centimetres)? *
When did your stroke(s) occur? *
Has a Mental Health Clinician or Medical Professional ever diagnosed or discussed any of the following with you? (Check all that apply) *	Diabetes IBD/IBS Sleep Apnea Autoimmune Disorders Substance Use Disorders Depression Anxiety PTSD C-PTSD OCD Eating Disorders PMDD Other N/A
Please share which other conditions you have been diagnosed with or have discussed with a professional
Have you ever witnessed or experienced a traumatic event? *	Yes No Unsure
Has this ever been addressed in therapy? *	Yes No Unsure
Have you been admitted to a hospital for a mental health or substance use-related issue in the past? *	Yes No Unsure
Have you ever had thoughts of wanting to die, or have a history of suicide attempts? *	Yes No
Please describe your history of suicidal thoughts and/or attempts and include dates, treatment, and hospitalizations. *
Describe your current support network. Please include family, partners, friends, pets, relatives, colleagues, therapists, or community members that you feel are appropriate. *
Do you have any active injuries, mobility limitations or special accommodation needs? *	Yes No
Are you able to independently walk up and down stairs? *	Yes No
Please share what kind of support is needed *
Do you have any allergies? *	Yes No
Please list your allergies *
Do you have any severe or potentially life-threatening allergies that would require the use of an EpiPen? *	Yes No
Do you agree to travel with your own EpiPen? *	Yes No
Are you pregnant or planning to become pregnant? *	Yes No
Are you adopted? *	Yes No

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5 Referral

How did you first find out about MycoMeditations? *
Please elaborate further if possible (ie: which podcast, which article, which therapist referred you, which family/friend referred you, etc.) *
If applicable, please enter the first and last name of the person who referred you to MycoMeditations:	Note that in order for you to receive their referral discount you must enter their full name here. (MycoMeditations will not accept postdated requests for referral credit under any circumstances.)

6 Terms, Conditions and Attestations

Valid Passport Agreement *	Check this box if you have read and understand the Valid Passport AgreementBy checking this box, I agree to ensure that I will have a valid passport to travel to Jamaica for any scheduled retreat. I understand that a refund or personal credit will not be issued should I be unable to board my flight due to an invalid passport.
Health Screening and Full Disclosure *	Check this box if you have read and understand the Health Screening and Full DisclosureBy checking this box and typing my name in the field below, I acknowledge that MycoMeditations will rely on the information provided in this application to screen for risk factors that may preclude me from attending a retreat, as a matter of my own safety. I hereby attest that the information provided is true and complete, to the best of my knowledge. All information I have provided in the application is correct and current. I also agree to promptly notify MycoMeditations of any new diagnoses or changes to the application information provided that may occur between now and when I attend retreat. I understand that my attendance at the retreat for which I am applying and/or access to psilocybin mushrooms may be denied at the sole discretion of MycoMeditations, if (1) it is determined that relevant information has been falsified or omitted on my application or (2) I exhibit dangerous behavior or seem too unstable for psilocybin mushrooms at any point during the process. I also understand that I am not entitled to a refund in either of these circumstances. Note and disclaimer: In some cases, you will be contacted personally by one of our staff to ensure that you are prepared for the experience. Our retreat venue is not a medical facility, and its owners, staff, employees, and agents are not licensed medical doctors, psychologists, or psychiatrists. We do not practice medicine, diagnose, cure, or treat disease or illnesses. Instead, we function as guides and facilitate the effects that psilocybin mushrooms have on people.
Acting on Own Behalf *	Check this box if you have read and understand the requirement to Act on your Own BehalfBy checking this box and typing my name in the field below, I attest that I am submitting this application on my own behalf, that all information included is in regards to my own personal information, and that I am not submitting this application on behalf of anybody else.
Psychiatric Medications Notice *	Check this box if you have read and understand the Psychiatric Medications NoticeBy checking this box and typing my name in the field below, I understand that: 1. If I choose to attend a MycoMeditations retreat without tapering off my medications that there is a significant chance that my experience with psilocybin mushrooms will be reduced. 2. I should not make any changes to my use of prescribed psychiatric medications until I have consulted with a licensed medical professional. 3. If there are any changes to my medications between now and when I attend my retreat, I must promptly notify MycoMeditations.
Medical Consultation for Prescription Medications *	Check this box if you have read and understand the Medical Consultation for Prescription MedicationsBy checking this box and typing my name in the filed below, I acknowledge that MycoMeditations representatives are not licensed to give advice on prescription medications and I agree to consult my doctor before discontinuing the use of any medications. If my doctor approves discontinuing my medications, I agree to follow the weaning process provided to me by my doctor.
Agreement to Read All Communications *	Check this box if you Agree to Read All CommunicationsBy checking this box and typing my name in the field below, I agree to read all emails, messages and attachments that are sent to me by MycoMeditations from the time of my application up to the retreat date. I understand that these communications will contain important information and instructions regarding my scheduled retreat, and some communications will require me to take actions that are pre-requisites for travel and/or for attending the retreat. If I fail to do so, and I miss an important requirement, I understand that I will not be refunded or allowed to transfer to a future retreat.
Accident and General Release of Liability Agreement *	Check this box if you have read and agree to Accident Waiver and General Release of Liability AgreementIn consideration of my application and permitting me to participate in this activity, the sufficiency of which is hereby acknowledged, I hereby take action for myself, and attest that such actions are binding upon, my executors, administrators, personal representatives, heirs, next of kin, successors, and assigns as follows: (A) I waive, release, and forever discharge from any and all liability, including but not limited to, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, the following entities or persons, hereinafter collectively referred to as “Releasees”: MycoMeditations Limited, JamTravel Enterprises, Inc., Magnificent Mushrooms Limited, accommodation facilities (including but not limited to Blue Marlin & Coquina Villas, Bluefields Bay Villas, Rainbow Tree Villas), Treasure Tours, Wise Wellness and/or their directors, officers, employees, independent contractors, vendors, volunteers, representatives, and agents, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named. (B) I indemnify, hold harmless, and promise not to sue the Releasees, individually or collectively, for any and all liabilities or claims made as a result of participation in this activity. (C) I acknowledge that Releasees are not responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. (D) I acknowledge that this activity may involve a test of a person’s physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, facilitators, and/or producers of the activity. These risks are not only inherent to participants, but are also present for employees, independent contractors and volunteers. (E) I hereby assume all of the risks of participating in any/all activities associated with this event I certify that I have sufficiently prepared or trained for participation in this activity, and have not been advised against participating by any qualified medical professional. I certify that there are no mental or physical health-related reasons or problems which preclude my participation in this activity. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. I acknowledge that this Accident Waiver and General Release of Liability Agreement will be relied upon by the Releasees and that it will govern my actions and responsibilities at the retreat. The Accident Waiver and General Release of Liability Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract and I agree to it of my own free will. By checking this box and typing my name in the field below, I hereby waive, release and hold harmless Releasees from any and all liability or responsibility for all injuries and/or damages or claims which may occur in the event I do attend the retreat.
Confidentiality Agreement *	Check this box if you have read and understand the Confidentiality AgreementBy checking this box and typing my name in the field below, I recognize and agree that any and all information shared with me as part of my participation in this retreat is confidential and/or proprietary, and this confidential and/or proprietary information shall not be divulged to any third party, such as the media, unauthorized individuals, agencies or organizations. This information includes, but is not limited to, medical and mental health information about other retreat participants, and trade-secrets, know-how, standard operating procedures and protocols of MycoMeditations. If I am a journalist or other member of the media, I agree and understand that my attendance at a retreat is solely for personal healing and growth purposes, and the details cannot be used for any publication, article, documentary or media purposes. All media inquiries should be directed to the CEO for a separate and distinct discussion outside of the scope of this Agreement .

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Guest 1		First Name* Last Name* Email*
Guest 1		First Name* Last Name* Email*