I, the undersigned, accept the conditions of participating in ayahuasca & DMT sessions held By the registered members and ministers of Eternal Self Ministries, and I declare that I am choosing to participate of my own free will. I have not been coerced into participating in sessions by the organizers or by any other person; the decision to participate is mine alone, and is based on my own personal assessment of the effects, the exclusion criteria, the potential risks and benefits, the focus of the session and the commitment of the people running it. I am aware that I am to answer all questions honestly during the screening process and am required to complete questionnaires before and after the session. I agree to provide all the relevant information about my medical history, my mental and physical health and any other information that may serve to protect my health during this process.

I acknowledge that the information I provide to the organizers of this session is strictly confidential and will not be used without my approval for any other purpose than as described in the accompanying document. I am aware that I can ask questions about the session at any time and can change my mind about attending at any time before the session begins. Once the session has started, I commit to not leaving the space without the consent of the person running the session, and I commit to following the instructions always, from the preparatory stage through to integration. I understand and agree that I can be excluded from participation in a session at the discretion of the facilitator. I understand that I will receive a copy of this consent form.

Eternal Self Ministries of the Malachian Empire recognizes the spiritual significance and ceremonial use of DMT and Ayahuasca. However, it is important to note that these substances may interact with other drugs and medications, resulting in adverse reactions.

Prescription Medications: If you are taking any prescription medications, it is crucial to consult with your healthcare provider before participating in a DMT or Ayahuasca ceremony. These substances can have significant interactions with medications, particularly antidepressants, and other psychotropic medications, potentially leading to serious health consequences.
Over-the-Counter Medications and Supplements: Similar caution should be exercised with over-the-counter medications and dietary supplements. Certain supplements and non-prescription drugs may interact adversely with DMT or Ayahuasca.
Alcohol and Recreational Drugs: The use of alcohol and other recreational drugs in combination with DMT or Ayahuasca is strongly discouraged due to the potential for harmful interactions.
Pre-existing Medical Conditions: Individuals with pre-existing medical conditions, particularly mental health disorders, heart disease, or liver disease, should consult a healthcare provider before using DMT or Ayahuasca.

While we respect and honor the sacredness of these traditional practices, the safety and well-being of our community members are paramount. It is your responsibility to ensure you are medically and physically fit to partake in such activities. This information is intended as a general guide and does not replace professional medical advice. Always consult a healthcare provider for personalized advice.

Eternal Self Ministries of the Malachian Empire assumes no liability for any adverse effects that arise from the use of these substances. Participation in any ceremony involving the use of DMT or Ayahuasca is done at the participant's own risk.

The religious ceremonies and sacred practices at Eternal Self Ministries often involve the use of Ayahuasca & DMT, natural substances known for their strong psychotropic effects. While these substances have been used safely in religious and spiritual ceremonies for centuries, there can be contraindications when combined with certain medications or drugs.

It is absolutely vital for any participant to be transparent about their medical history and current medication usage, both prescription and over-the-counter, as well as any illicit substances. This includes but is not limited to antidepressants, especially those in the class of Monoamine Oxidase Inhibitors (MAOIs) and Selective Serotonin Reuptake Inhibitors (SSRIs), blood pressure medications, immune system modulators, mood stabilizers, antipsychotics, and certain common over-the-counter medications like decongestants.

Additionally, the use of illicit substances including but not limited to cocaine, amphetamines, MDMA (ecstasy), and certain prescription medications not taken as prescribed, can interact dangerously with Ayahuasca & DMT.

The combination of these substances with Ayahuasca & DMT can lead to severe health risks including hypertension, heart attack, serotonin syndrome, and in rare cases, even death.

It is also important to consider the psychological readiness for participating in a ceremony involving Ayahuasca & DMT, as these substances can bring up intense and sometimes disturbing emotional and psychological material.

Your safety is our utmost priority at Eternal Self Ministries. It is your responsibility to inform us about your health condition and medication usage. We recommend seeking advice from a healthcare professional if you are unsure. Your honesty and transparency are key to ensuring your safety and maximizing the potential benefits of the ceremony.

The Eternal Self Ministries cannot be held liable for any health issues or adverse effects arising due to the participant's failure to disclose their full medical history and medication usage, and failure to comply with the guidelines set forth.

Abilify •Actifed • Adderall • Alaproclate • Albuterol (Proventil, Ventolin) • Amantadine hydrochloride (Symmetrel) • Ambien • Amineptine • Amitriptaline • Amoxapine (Asendin) • Atomoxedine • Baclofen •Befloxetone • Belsomra •Benadryl • Benylin • Benzedrine • Benzodiazepine• Benzphetamine (Didrex) • Bicifadine • Brasofensine • Brofaromine • Bupropion (Wellbutrin) 3 • Buspirone (BuSpar) • Butriptyline • Carbamazepine (Tegretol, Epitol • Chlorpheniramine • Chlor Trimeton • Celexa •Cimoxetone • Citalopram • Clonidine • Clonazapem • Clomipramine (Anafranil) • Codeine • Cyclobenzaprine (Flexeril) •Cyclizine (Marezine) • Cymbalta• Dapoxotine • Desipramine (Pertofrane, Norpramin) • Desvenlafaxine • Dextroamphetamine (Dexedrine) • Dextromethorphan (DXM) • Diazepam • Diethylpropion ) •Dibenzepin • Dienolide kavapyrone desmethoxyyangonin • Diethylpropion • Diphenoxylate Disopyramide (Norpace) • Disulfiram (Antabuse) • Dopamine (Intropin) • Dosulepin • Doxepin (Sinequan) • Duloxetine • Emsam • Ephedrine • Epinephrine (Adrenalin) • Escitalopram • Femoxitine • Fenfluramine (Pondimin) • Flavoxate Hydrochloride (Urispas) 4 • Fluoxetine (Prozac) • Fluvoxamine • Furazolidone (Furoxone) • Guanethedine • Guanadrel (Hylorel) • Guanethidine (Ismelin) • Hydralazine (Apresoline) • Hydrocodone • 5 Hydroxytryptophan • Imipramine (Tofranil) • Iprindole • Iproniazid (Marsilid, Iprozid, Ipronid, Rivivol, Propilniazida) • Iproclozide • Isocarboxazid (Marplan) • Isoniazid (Laniazid, Nydrazid) • Isoniazid rifampin (Rifamate, Rimactane) • Isoproterenol (Isuprel) • L dopa (Sinemet) • Lamictal •Levodopa (Dopar, Larodopa • Linezolid (Zyvox, Zyvoxid) • Lithium (Eskalith) • Lofepramine • Loratadine (Claritin) •Lorazepam• Lunesta• Luvox •Lyrica •Maprotiline (Ludiomil) • Maxalt •Medifoxamine • Melitracen • Meperidine (Demerol) • Metaproterenol (Alupent, Metaprel) • Metaraminol (Aramine) • Methadone• Methamphetamine (Desoxyn) • Methocarbamol• Methyldopa (Aidomet) • Methylphenidate (Ritalin) • Mianserin • Milnacipran • Minaprine 5 • Mirtazapine (Remeron) • Moclobemide • Montelukast (Singulair) • Naltrexone • Nefazodone • Nialamide • Nisoxetine • Nomifensine • Norepinephrine (Levophed) • Nortriptyline (Aventyl) • Oxybutynin chloride (Ditropan) • Oxymetazoline (Afrin) • Orphenadrine (Norflex) • Pargyline (Eutonyl) • Parnate • Paroxetine (Paxil) • Pemoline (Cylert) • Percocet • Pethedine (Demerol) • Phendimetrazine (Plegiline) • Phenergen • Phenmetrazine • Phentermine • Phenylephrine (Dimetane, Dristan decongestant, Neo Synephrine) • Phenylpropanolamine (in many cold medicines) • Phenelzine (Nardil) •Phenibut • Plaquenil •Pregablin •Procarbazine (Matulane) • Procainamide (Pronestyl) • Protriptyline (Vivactil) 6 • Pristiq • Prozac•Pseudoephedrine • Oxymetazoline (Afrin) • Quinidine (Quinidex) • Rasagiline (Azilect) • Reboxetine • Remeron • Reserpine (Serpasil) • Risperidone • Robaxin• Salbutemol • Salmeterol • Selegiline (Eldepryl) • Sertraline (Zoloft) • Sibutramine • Suboxone• Subutex•Sumatriptan (Imitrex) • Terfenadine (Seldane D) • Tegretol • Temaril • Tesofensine • Theophylline (Theo Dur) • Tianeptine • Tizadine •Toloxatone • Tramidol • Tranylcypromine (Parnate) • Trazodone • Tricyclic antidepressants (Amitriptyline, Elavil) • Trimipramine (Surmontil) • Triptans • Vanoxerine • Venlafaxine (Effexor) • Viloxezine • Vraylar •Welbutrin• Yohimbine • Zimelidine • Ziprasidone (Geodon) • Zoloft These drugs and medications can be dangerous with Ayahuasca: ▪ other MAOIs ▪ SSRI’s (any selective serotonin reuptake in- 7 hibitor) ▪ antihypertensives (high blood pressure medicine) ▪ appetite suppressants (diet pills) ▪ medicine for asthma, bronchitis, or other breathing problems; antihistamines, medicines for colds, sinus problems, hay fever, or allergies (Actifed DM, Benadryl, Benylin, Chlor-Trimeton, Compoz, Bro- marest-DM or -DX, Dimetane-DX cough syrup, Dristan Cold & Flu, Phenergan with Dextromethorphan, Robitussin-DM, Vicks Formula 44-D, several Tylenol cold, cough, and flu preparations, and many others — any drug containing dextromethorphan/ DXM or with DM, DX or Tuss in its name.) ▪ CNS (central nervous system) depressants (xanax, ativan, etc) ▪ vasodilators ▪ antipsychotics ▪ barbiturates ▪ alcohol

Using cocaine, amphetamines or MDMA (Ecstasy) with MAO-Is may cause a severe increase in blood pressure, increasing the chances for stroke and cerebral hemorrhage and making it possible to overdose on a relatively small amount of cocaine. (A fatality has been recorded involving combining Peganum harmala and cocaine. Fatalities resulting from combining amphetamines with pharmaceutical MAO-Is are recorded in medical literature.) • Using other serotonin agonists or precursors with an MAO-I can lead to serotonin syndrome. The main symptom of serotonin symptom may be a severe and long-lasting headache (the same symptom as MAO-I tryptamine interaction) and/or fever (as high as 40 °C / 104 °F or more) Other symptoms of serotonin syndrome may include rapid heartbeat, shivering, sweating, dilated pupils, intermittent tremor or twitching, overactive or over-responsive reflexes, hyperactive bowel sounds, high blood pressure. Severe serotonin syndrome may lead to shock, agitated delirium, muscular rigidity and high muscular tension. renal failure, seizures, and can be life-threatening/LETHAL.

Endorsed by Eternal Self Ministries, I acknowledge that sessions might encompass tactile interaction, applied physical pressure, facilitated movement, the practice of laying hands, emotional, mental, psychological, and spiritual guidance, various exercises, and the potential use of natural plant-based substances, herbs, oils, and other materials, in addition to the rituals, ceremonies, and sacraments as administered by Eternal Self Ministries.

Furthermore, I comprehend and agree to maintain all current prescribed medications and other therapeutic modalities until explicitly advised otherwise by the prescribing practitioner. I concede that Eternal Self Ministries operates under ecclesiastical jurisdiction and retains sole authority to determine, decide, or resolve any matter of disagreement or dispute between the participating parties herein.

In case of any dissatisfaction arising from services provided by a Member or for any other reason, I understand that I reserve the right to lodge a formal complaint through the Disciplinary Council division of Eternal Self Ministries. This can be done either through email at [email protected] or by traditional mail to: 2158 45th St Ste 137 Highland, IN 46322.

Upon receiving a legal complaint, Eternal Self Ministries will conduct a comprehensive investigation aligned with our Code of Ethical Standards. If Eternal Self Ministries identifies enough evidence to warrant a formal inquiry, we will constitute an arbitral tribunal, acting as the sole agreed-upon solution to review and pass judgment on such a complaint.

I acknowledge that all procedures including, but not limited to, Native Indigenous Ceremonies and Medicines, Sacraments, meditations, affirmations, energy exchanges, prayers, Yoga practices, therapies, sessions, protocols, Laying on of Hands (Chirothesia), and other natural, non-invasive, holistic practices, ceremonies, and healing conversations are private practices performed by authorized members of the Ecclesiastical/Church Domain and Eternal Self Ministries.

Eternal Self Ministries operates as a 508(c)(1)(a) Faith Based Organization (FBO), a non-profit religious entity exempt from tax. This organization is distinct from 501(c)(3) charities and unincorporated FBOs. By definition, an unincorporated FBO is a First Amendment Church/Organization. A 508(c)(1)(a) FBO is recognized by the Federal Government, all 50 states, and internationally under the Hague Convention of the United Nations Charter.

As a member of Eternal Self Ministries, I understand and agree that I am not availing these services as a public member. I also understand and commit that whenever I book a weekend retreat, I will donate 10% of the total cost as tithing, in adherence to the principles of Eternal Self Ministries.

I am an adult, aged 18 or older, legally and mentally competent to make informed decisions regarding my sincerely held religious beliefs, health, wellness and recreation. Additionally, I acknowledge that I am here on this day and every subsequent visit solely on my own behalf and not as an agent of any governmental agency. I swear that all information provided by me in support of receiving services from the above referenced practitioner are correct and true as a Pre-condition towards participating in any private Eternal Self Ministries counseling or wellness activities. NINTH AMENDMENT DECLARATION: ARTICLE IX, U.S. CONSTITUTION

“The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the People.” Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health care (or psychological services, or educational services, etc...). This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by the fellow member, therapist, doctor or any practitioner of my choice. The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time.

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS Church’s and its retreats, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous activates or defective equipment or property owned, maintained, or controlled by them, drinking of Ayahuasca, partaking of Rapé participating in a Kambô Cleanse, Vaping DMT or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in this ceremonial ritual, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems or on any medications which preclude my participation in this activity. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the Church, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my travelling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: Eternal Self Ministries and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers; (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I acknowledge that Eternal Self Ministries and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. 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, drinking of Ayahuasca, partaking of Rapé participating in a Kambô Cleanse, Vaping DMT, lack of hydration, excessive hydration and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but are also present for volunteers.

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 understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate medical purpose by the activity holders, medical team, producers, sponsors, organizers, and assigns. I agree if I do not want my picture to be used at all I will let the Eternal Self Ministries and its organizers know in a written statement. The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

Please note that there will be no refunds or discounts for arriving late, leaving early, flight cancellations, travel delays or illness or wide spread illness. If you cancel your participation in a retreat for any reason, the cancellation policy below will apply, with no exceptions. We wish we could compensate people for unforeseen circumstances (injury, family emergency, etc.), but we have incurred costs upon receiving reservations for the retreat centers and hotels. We have designed our cancellation policy to be as compassionate as possible in the case that your plans change. To protect yourself further, we strongly encourage you to purchase travel insurance.

We recommend TRAVELGUARD, which offers a variety of travel insurances, including the option for a comprehensive “cancel for any reason” policy. If you cancel your retreat – for any reason – your airfare, hotel, retreat costs, etc. up until 48 hours prior to travel, it will be covered. This comprehensive package is called the” Gold Package Cancel for Any Reason Policy”. You must contact Travel guard and purchase the policy within 15 days of buying your airline tickets or incurring any costs for any part of your travel. You can also choose to insure only your air tickets. Travel guard can give you quotes for each scenario. Eternal Self Ministries is not affiliated with Travel guard.

This CONSENT must be READ in full and signed by the PATIENT who is opting of their own volition to continue their retreat at Eternal Self Ministries despite the National Pandemic Emergency. As part of being in any CLINICAL healing environment, PATIENTS may be inadvertently EXPOSED to a greater risk of the Coronavirus (COVID-19) despite our best attempts at physical distancing and heavy sanitation procedures. Eternal Self Ministries places the health and safety of our guests at the forefront and is, therefore, neither insisting nor recommending that guests CONTINUE with care based on this unprecedented COVID-19 pandemic.

Guests who choose to continue acknowledge that they are fully appreciative of the potential health risks of doing so and ACCEPT any RISKS themselves and agree to NOT hold our practice liable in any way from our good faith efforts and care being offered during this crisis. Furthermore, guests opting to continue in the current state of affairs UNDERSTAND and ACKNOWLEDGE that they forever RELEASE and DISCHARGE Eternal Self Ministries and staff from any and all liability that is attributable to or related to the Coronavirus or any claims of contracting the Coronavirus as a result of receiving care from Eternal Self Ministries. The Member acknowledges and warrants he/she has READ all parts of this agreement and fully ACCEPTS and understands its terms.