E A R T H

Name *

First Name

Last Name

What is your birthdate? *

MM

DD

YYYY

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

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During EARTH you will be invited to unplug from work, social media, & phone in order to best uplift and support your full presence in this immersive space. *

I am ready to be fully present.

We are choosing to hold EARTH as a plant medicine/substance free and fully present space. We ask each who participate to do the same. *

I understand & agree to stay present, sober, and uphold a plant medicine/substance free space at EARTH.

FINANCIAL AGREEMENT *

A deposit of $555 is required to reserve your space upon agreement. Full financial commitment is required to be paid in full, a week prior to the set date of the immersion. There are no refunds for this immersion. The payments are transferrable. Payment plans will be available.

I affirm that I have read, understand, and agree to the financial agreement above.