6 (or 7) Day Ayahuasca & San Pedro Retreat with Yoga & Meditation / Dec 14 – 19, 2024

December 14 - 19, 2024

* These fields are required

People in your group

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

After completing this form, emails will be sent to everyone in your group to complete their information.

Optional Items

REQUIRED - Round Trip Airport Transfer

**REQUIRED** You must check this box for a Round Trip Airport Transfer. This is not optional as we are an hour outside of Cuenca and there is no dependable public transportation to and from the center. We are truly rural in the mountains, no road names and no regular taxi drivers are be able to find us.

$48.00

Select quantity

No Karma Yoga - 6 Days

Your retreat price is discounted upfront with participation in our 1hr per day Karma Yoga. Karma Yoga is part of community life, maintaining common spaces, weeding gardens, sweeping floors, doing dishes, watering plants, bringing in firewood, etc. You are welcome to do a few hours at once or 1 per day. It's up to you! If you do not wish to participate in our Karma Yoga program, you can select to opt out and pay the difference ahead of your arrival, $10 for each day of the retreat. To ensure fairness for all involved, if by the end of the retreat you have not completed the agreed number of Karma Yoga hours we will charge your card for the remaining balance, $10 for every hour not completed.

$60.00

Select quantity

Shamanic Cleansing (Limpia)

The shamanic cleansing is a really wonderful way for you to have a one-on-one with the shaman at the beginning of the retreat. The shaman spends 30-45 minutes with you privately to help you clear your energy, address any physical issues that you might have, and get you ready for the ceremonies that follow in the retreat.

$35.00

Select quantity

Laundry

Do you want to pay for a load of laundry? Some people find that they need to do laundry at some point during the retreat. Your clothes are washed, dried and folded for you.

$5.00

Select quantity

Security Box - 6 Days

Not needed if you are in private room or apartment. Bring your own padlock, mid sized.

$6.00

Extra Ayahuasca Ceremony - Saturday

This ceremony is on Day 8 of the 12 day retreat, and Day 1 of the 6 day retreat. If you are in the 6 day retreat you may wish to book 1 night early to settle in. If doing this extra ceremony on day of arrival, don't eat food after lunch, but please drink water all day. This ceremony begins at 5:30 pm. You will also have the option to decide later and pay for this ceremony once you are at the retreat.

$185.00

Select quantity

Heater - 6 Days

PRIVATE AND SHARED ROOMS ONLY ($2.25 per day) Apartments come with gas heater, dorms are not able to have heaters. Heaters are not really necessary, but it can get chilly at night if you plan to spend time in your room and not with the group at the campfire or community center with the woodstove. Please do not run the heater when you are not in the room, it is a fire hazard.

$18.00

Participant Info

First Name *
Last Name *
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Phone *
Email *
2nd Email (in case 1st one doesn't work)
Do you have a passport? (6 months on passport required at time of entry into Ecuador) *	Yes No
Birth Date *
Age *
Gender *	Please choose your biological sex at birth. No one can room with the opposite sex in a shared room or dormitory situation without other people's consent. If you are not willing to room with your biological birth sex, please choose a private room in consideration for others. We welcome transgender people here, but it is not fair to force sharing a room with a stranger of the opposite biological sex without their consent. if you are coming with a friend, please to let us know you want to room together if choosing a shared room.
Are you a University of Metaphysical Sciences student?	Yes No 5% discount for UMS students.
If Yes, please enter your Student ID number and enter the discount code: "UMS Student Discount” in the space below.
Discount code	Please enter any other discount codes here and click Apply
Have you been to Gaia Sagrada before? *	Please answer yes or no. If yes, let us know whether you were here as a guest or a member of our Work Exchange Program
Where did you hear about Gaia Sagrada? *	Google Other Internet search engine Internet ad Facebook Other social site Aya Advisors Retreat Guru Trip Advisor Travel agency Friend Other (website, place, store) Card or pamphlet (There may be special commission code) Check all the apply
If you clicked "other" in the list above, please tell us here:
Arrival Date *	If you come a day or two before the retreat, please enter date you arrive. Here are the prices for non-retreat nights at Gaia Sagrada Click Here Food is included.
Departure Date *	If you stay a day or two after the retreat, please enter date you depart.
If you cannot book your first housing option, what is your second housing choice? We can put you on the waiting list as sometimes there is a cancellation *	I received my first housing option Dormitory Shared Room (Shared Bath) Shared Room (Private Bath) Private Room (Shared Bath Private Room (Half Bath) Private Room (Full Bath) One Bedroom Apartment (single occupancy) One Bedroom Apartment (double occupancy)
Do you snore? *	Yes No
What has attracted you to come stay at Gaia Sagrada? *
Please tell us what you are looking to attain or heal at this retreat? Also, please tell us if there is anything you would like to share about yourself. We would love to know more about you if you care to share. *
Please enter your Facebook url or any other website you would like to share here.
Name of who you plan to room with if coming with someone else?
Email newsletter	Please send me the email newsletterThis email list is connected to University of Metaphysical Sciences (our sponsoring 501(c)3 non profit organization). We don't send emails out very often, so we promise you won't be bombarded. Also, we never share our lists with anyone else, so you will only get emails from us.

Health & Medical Questions

Do you have any current medical issues or conditions? (asthma, diabetes, epilepsy etc). *	Help us keep you safe. If we know about medical conditions you have we can be prepared for your needs.
Do you have any heart conditions? Please explain *
Do you have a current mental illness that we need to know about? (bipolar, dementia, schizophrenia, anxiety disorders etc). *
Are you taking any antidepressants or antipsychotic medications? *
Are you currently taking any other medications? *	It is important we know this as some medications are not compatible with Ayahuasca.
Do you have any allergies? *	Please details and let us know you handle them? (Medications, avoidance of things you’re allergic to, etc.) Please let us know if there is anything we can do to help keep your allergies from surfacing.
Please tell us about any of your dietary restrictions. *
Have you had a surgical operation in the past year or will have an operation soon? *	Please explain your condition and procedures needed.
Both UNvaccinated and vaccinated travelers can enter Ecuador. We do not discriminate against one or the other but for your safety we need to know what is your vaccination status and are you ok with no one wearing masks? *

Emergency Contacts

For each emergency contact, please include name and relationship to you, address, phone number, and email address. We will not contact either person unless there is an emergency and we will not put either one on an email list. We respect privacy rights.

Emergency Contact #1 First Name and Last Name *
Emergency Contact #1 - Relation to you *	Father, mother, brother, sister, friend, etc.
Emergency Contact #1 Phone *	Please include the international country calling code
Emergency Contact #1 Email *
Emergency Contact #1 Confirm Email *
Emergency Contact #1 Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Emergency Contact #2 First Name and Last Name *
Emergency Contact #2 - Relation to you *	(father, mother, brother, sister, friend, etc.)
Emergency Contact #2 Phone *	Please include the international country calling code
Emergency Contact #2 Email *
Emergency Contact #2 Confirm Email *
Emergency Contact #2 Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *

Agreements

HEALTH & MEDICAL AGREEMENT *	Yes No I understand that Gaia Sagrada cannot provide me with medical attention nor does Gaia Sagrada have a doctor or nurse on site. I understand that the hospital is approximately an hour away. I am alerting Gaia Sagrada in the "special dietary or medical needs" section if I have health conditions which staff needs to know about for my safety. By submitting my reservation for a Shamanic Ceremony Retreat at Gaia Sagrada, or any other type of stay at Gaia Sagrada, I understand that my health and well-being is my responsibility and not that of Gaia Sagrada, staff, or associates thereof. I am bringing medicines I need with me, I have consulted with my doctor if I feel the need, and I have enough money to take care of my own health needs. If I have signed up for the shamanic retreat, or choose to when I am there, I take full responsibility for my experiences or reactions to the Sacred Ceremonies. I choose to participate in Sacred Ceremonies, or simply stay at Gaia Sagrada without being a participant in the retreats, of my own free will. If participating in the shamanic ceremonies, I know that I will be partaking in plant medicine teas. Whatever type of stay at Gaia Sagrada I choose, I promise to be careful, follow directions, and ask for help if I should need assistance in any way whatsoever.
LEGAL RESPONSIBILITY & REFUND AGREEMENT *	Yes No By submitting this reservation, I do not hold Gaia Sagrada, University of Metaphysical Sciences, Wisdom of the Heart Church, nor any employee thereof responsible for my belongings, health issues, or any other unforeseen circumstances. I have read and agree to the cancellation/refund policies Click Here and understand that all events, classes, workshops, and retreats are for entertainment and relaxation purposes only, not therapeutic in nature.
COVID-19 RISK *	Yes No I, of sound mind, understand that there is an ongoing global COVID-19 pandemic and that travelling to Gaia Sagrada and to Ecuador, for a retreat or a monthly stay, is not risk free. I take total responsibility for my own health and any medical expenses that may arise due to my decision to travel. I agree that if I were to fall ill during my time at Gaia Sagrada with any cold or flu-like symptoms, I will immediately enter into isolation. Refusal to isolate will result in my immediate dismissal from Gaia Sagrada. I agree that if I were to become sick with COVID-19, or any other virus, I will not hold Gaia Sagrada responsible. I acknowledge that social distancing and facemasks etc are not an option for retreats at Gaia Sagrada and that Gaia Sagrada cannot guarantee a virus free zone, although certain precautions will be taken. I agree to take full responsibility for my decision to attend a retreat or monthly stay at Gaia Sagrada
Are You Vaccinated Or Unvaccinated? *	Yes, I am fully vaccinated No, I am NOT vaccinated We do not discriminate between vaccinated or unvaccinated, but it is important for us to know for health reasons in case there are any emergencies. We have not seen any issues, but if there are we would want to be able to inform a doctor if if a person is vaccinated or not. Thank you for understanding!
Comments or anything else you would like to share!

Payment

Sub Total	$0

Taxes	$0

50% Deposit	$0

Due Now	$0 $0

First Name
Last Name
Card Number *
Card Expiration *	Month Year
Card Security Code	usually a 3 digit code on back of card

6 (or 7) Day Ayahuasca & San Pedro Retreat with Yoga & Meditation / Dec 14 – 19, 2024

Price

Select an option*

1 Bedroom House - (Single or Double Occupancy same price)

Apartment (Double Occupancy)

Apartment (Single Occupancy)

Dormitory (Female)

Dormitory (Male)

Private Room (Half Bath)

Private Room (Shared Bath)

Private Room - (Full Bath)

Shared Room - Bunk Bed (Half Bath)

Shared Room (Couples) - Queen Bed (Full Bath)

Shared Room (Couples) - Double Bed (Shared Bath)

Shared Room - Bunk Beds (Full Bath)

Shared Room - Bunk Bed (Shared Bath)

People in your group

Optional Items

Participant Info

Health & Medical Questions

Emergency Contacts

Agreements

Payment