Small Group Session (2 people)

Before provider will agree to provide Kambo and allow you to attend the Kambo Practitioner Training, this form must be read and signed by the participant.

Participant acknowledges that they will be and have been truthful in giving full disclosure of their mental and physical health conditions. Participant has reviewed any literature provided and may have done some independent research of their own; and has asked Provider all questions they have regarding Kambo and the Kambo Practitioner Training Program. Participant acknowledges that they understood and are happy with the information and answers provided. That you are not under the influence of any drugs or alcohol, that you are not impaired in any way that would affect your decision making and that you are not under any duress. That you freely and voluntarily give permission to Provider to provide you with a Kambo session and the Kambo Practitioner Training now and in the future. That the Provider is not a medical professional and Kambo is not approved by the government as a medical treatment. That no results are guaranteed from Kambo sessions.

Kambo does have significant effects on your body and these have been reviewed by you. In rare cases Kambo can result in loss of consciousness. By signing below you give permission to Provider to use the training they have had to help you regain consciousness in such an event, and if, in the judgment of the Provider you should require medical treatment, you also give permission for medical professionals to be called to provide necessary treatment to you.

In consideration of the services provided by the Provider, Participant releases all claims against Provider. The undersigned acknowledges, appreciates, and agrees that:

1.  The risk of being harmed from Kambo can be significant in rare cases, including the potential for permanent disability and death, and while the Provider’s training reduces the risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the program’s stated and customary terms and conditions for participation.,
4. I for myself, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE PROVIDER, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my participation in the Kambo sessions and Kambo Practitioner Training, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
5. I, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all of the above Releasees from any and all liabilities incident to my participation, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.
6. I certify that I do not suffer from any health conditions that would prohibit my participation in Kambo sessions and the Kambo Practitioner Training, and hereby consent and allow Provider to proceed with the Kambo session(s) and Kambo Practitioner Training under the terms and conditions provided herein including all the Releases, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless Provider and all personnel connected therewith, from any and all liability from any claim that arises out of decisions made per this release and all damages resulting from participation in the Kambo session(s) and Kambo Practitioner Training as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE.