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Antigua and Barbuda
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Bosnia and Herzegovina
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Central African Republic
Congo, Democratic Republic of the
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Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
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Palestine, State of
Papua New Guinea
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Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
What draws you to the idea of psychedelic spirituality and the use of psychedelics in religious practice?
Have you had previous experience with psychedelics, and if so, how have these experiences impacted your spiritual or personal growth?
What is your understanding of the potential risks and benefits of using psychedelics, and how do you plan to approach their use responsibly and with reverence?
Please let us know if you have any medical or psychological conditions. We welcome all individuals, regardless of diagnosis, but reserve the right to determine the appropriateness of our medicines on a case-by-case basis.
What do you hope to gain from membership in our temple, and how do you envision contributing to the community and its mission?
Are you willing to participate in our temple's training and orientation program, which includes education on psychedelics, harm reduction, and the spiritual principles that guide our community?
What other spiritual practices or disciplines have you explored, and how do you see these practices intersecting with your use of psychedelics?
As a condition of participation in this membership application, we ask that you confirm that you are solely here for a spiritual experience and not for any Law enforcement or investigative purposes. Please type 'Yes' and your full name in the space provided to confirm your affirmation.
Are there other insterests not listed above that you would like to share?
MEDICAL RELEASE STATEMENT
I accept the terms of the MEDICAL RELEASE STATEMENT
In consideration of being allowed to participate in this event, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the event's leader, organizers and participants from any and all liability, claims, demands, or course of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me whether caused by the negligence of release, or otherwise, while participating in this event, or while in, on or upon the premises where the event is being conducted.
To the best of my knowledge, I am in good physical condition and I am not aware of any physical and physiological infirmity, which would place me at risk to participate in any way with the ceremony activities. I am fully aware of the risks and hazards connected with this event. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE, ILLNESS, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the event's activities whether caused by the negligence of release, or otherwise. By selecting "Yes, I accept the terms of this Medical Release Statement" below, I am acknowledging and representing, in the same way that a signature would represent, that I have read and understand this Medical Release Statement and sign in voluntarily; I am least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete considerations fully intending to be bound by same.
PARTICIPATION AGREEMENT, WAIVER AND RELEASE OF LIABILITY
I accept the terms of the PARTICIPATION AGREEMENT, WAIVER AND RELEASE OF LIABILITY
By confirming my agreement to this waiver, I acknowledge that I have carefully read this document and fully understand its terms and conditions and that this is a release and waiver of all liability with regard to any rights I may have to seek compensation in the case of any loss, damage, illness, or injury, including death.
I acknowledge the ceremonies I plan to participate in as part of my religious practice, in exercise of my freedom of religion and under protections of the First Amendment of the United States' laws and Constitution. As part of these religious ceremonies, I will consume the Psilocybin Sacrament. The Sacrament will be consecrated and served in religious and spiritual practice guided in ceremonial settings.
I understand that the Ceremonial settings in which I voluntarily choose to participate may be physically, mentally, emotionally, and/or spiritually demanding. I understand that I may experience dizziness, nausea or other physical upsets including vomiting and diarrhea. I accept full responsibility for anything that may occur including emotional disturbance, mental disorientation, and any and all possible manifestations of physical, emotional and/or mental changes. I acknowledge that the risks and potential benefits of my participation have been explained to me and I freely choose to enter this process accepting full responsibility for whatever may occur, anticipated or unanticipated.
I hereby knowingly and voluntarily assume the full risks of any physical or other injury, damage or losses, either to myself or caused to others by me during any of the Ceremonial settings. I am freely making monetary donations to help cover part of the expenses necessary to support the continuity of these Spiritual and Religious traditions for me and for future generations.
I understand I may be physically or mentally exhausted and/or disoriented after the Ceremonies, and I acknowledge that it is my responsibility to arrange alternate transportation, if needed.
I understand that although my participation in the Ceremonial settings is purely voluntary, I commit to follow all the instructions given.. I commit to stay in the Ceremonial space and at the Ceremony site until the end of the Religious service, and under no circumstances will I leave the premises, either on foot or by any vehicle before I am cleared by the Ceremonial guides to do so.
I understand, acknowledge, and agree to the importance of the privacy of the Ceremony, its participants, and the observations made of others during the Ceremony, and agree not to share any of this information and/or observations with anyone. Any emotional or other process that I happen to observe in others during the Ceremony will be kept strictly confidential and I agree to abstain from photographing, filming, or recording anything throughout the duration of the Ceremonies I am present for.
FOR GOOD AND VALUABLE CONSIDERATION, THE RECEIPT AND SUFFICIENCY OF WHICH IS HEREBY ACKNOWLEDGED, I DO HEREBY DISCHARGE AND COVENANT NOT TO SUE, AND RELEASE, HOLD HARMLESS, INDEMNIFY, AND FOREVER DISCHARGE PSILO TEMPLE, THE CEREMONIAL GUIDES, ORGANIZERS, MEMBERS, EMPLOYEES, AGENTS, STAFF, AFFILIATES, REPRESENTATIVES, CONTRACTORS, SUCCESSORS, ASSIGNS, RESPECTIVE HEIRS, PERSONAL REPRESENTATIVES, AND ALL PERSONS, FIRMS OR CORPORATIONS WHO MIGHT BE CLAIMED TO HAVE ANY LIABILITY, WHETHER OR NOT NAMED HEREIN (HEREINAFTER REFERRED TO AS "RELEASEES"), FROM ANY AND ALL LIABILITY FOR ANY LOSS, DAMAGE, EXPENSE OR INJURY, BOTH TO PERSON AND TO PROPERTY, INCLUDING DEATH, THAT I MAY SUFFER OR THAT ANY THIRD PARTY MAY SUFFER AS A RESULT OF MY PARTICIPATION OR IN ANY THIRD PARTY'S PARTICIPATION IN THE CEREMONY AND ANY OTHER RELATED ACTIVITIES, DUE TO ANY CAUSE WHATSOEVER INCLUDING NEGLIGENCE, GROSS NEGLIGENCE, BREACH OF CONTRACT, BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, AND/OR BREACH OF STANDARD OF CARE, ON THE PART OF THE RELEASEES, AND INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME OR OTHER THIRD PARTIES FROM THE RISKS, DANGERS, AND HAZARDS OF PARTICIPATION IN THE CEREMONY AND ANY OTHER RELATED ACTIVITIES.
I understand that the ceremony organizers do not carry personal liability insurance that covers my participation in the Ceremonial settings, and that I have the option to purchase such insurance.
I understand and agree that this Waiver and Release of Liability Agreement shall be binding upon my heirs, next of kin, executors, administrators, assignees, representatives, trustees, and guardians in the event of my death or incapacity.
I understand and agree that this Waiver and Release of Liability Agreement and any rights, duties, and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of the State of Oregon and no other jurisdiction, and any litigation involving the parties to this agreement shall be brought solely within the State of Oregon and shall be within the exclusive jurisdiction of the courts of the State of Oregon.
It is understood and agreed that this Waiver and Release of Liability Agreement is made in full and complete settlement and satisfaction of the aforesaid actions, causes of action, claims and demands and that this release contains the entire agreement between the parties. In entering this Waiver and Release of Liability Agreement I am not relying on any oral or written representations or statements made by the Releasees with respect to the Ceremonies and related activities other than what is set forth in this Waiver and Release of Liability Agreement.
I give permission to the Ceremonial Guides and Organizers to seek medical or other services for any injury or emotional distress.
To the best of my knowledge, I attest that I am in good physical condition and I am not aware of any physical and psychological infirmity that would place me at risk to participate in any way with the Ceremonial activities.
I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF LOSS, PROPERTY DAMAGE, ILLNESS, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in the Ceremonial activities, no matter the cause, anticipated or unanticipated.
I agree to defend, indemnify, and hold harmless ceremony guides, and religious leaders, and its officers, directors, members, employees, agents, staff, affiliates, representatives, contractors, successors, assigns, respective heirs, and personal representatives from and against any loss, liability, claim, action, or demand, including without limitation reasonable legal and accounting fees, alleging or resulting from my participation in the ceremony or in any related activities.
By selecting "Yes, I agree to the above terms," I am acknowledging and representing, in the same way that a signature would represent, that I have carefully read this document and fully understand its terms and conditions; that I have had time to reflect upon it; that this is a release of all liability; that I accept all of the terms of this agreement voluntarily; and that I am least eighteen (18) years of age and fully competent, and if I am not 18 years of age that I have signed approval below by a parent or guardian. I execute this Waiver and Release of Liability Agreement for full, adequate, and complete considerations and I fully intend to be bound by its terms.
PERSONAL USE STATEMENT
I accept the terms of the personal use PERSONAL USE STATEMENT
I understand that to qualify to receive sacrament for personal use, I must first agree to use it only for personal purposes and refrain from gifting or selling it. These measures help to prevent reselling and ensure that the sacrament is used responsibly.
- $30/month or $330/year
This level of membership is our basic membership. This is our minimum suggested level, it will help support our day to day operations and offerings.
l - $55/month or $605/year
As a supporter at this level, you’ll help us continue to build our offerings and provide robust opportunities for you and other members to experience spiritual growth.
- $85/month or $935/year
As a supporter at this level, you’ll be an integral part of our growth and success and help us achieve our goals.
*This level includes daily sacrament microdose subscription.
- $108/month or $1188/year
The Mycelium is the strongest part of the fungi. This is the immune system, the life force and also the part that helps the forest thrive including serving as a communication and resource sharing network.
*This level includes daily sacrament microdose subscription.
How often do you want to give?
Opting for an annual contribution affords a significant saving compared to monthly payments. To illustrate, the 'Spore Level' membership under a Monthly Contribution plan incurs an annual expense of $360. However, by selecting the Yearly Contribution option, the total cost is reduced to $330 for the same period. This represents a substantial saving over the course of a year.
Recurring Monthly Contribution
I would like to request financial assistance
Spore Level - $30/month
Pinning Level - $55/month
Fruiting Level - $85/month
Mycelial Level - $108/month
Together, we can achieve so much more than we ever could alone. While we are busy securing grant funding to support our mission, we cannot rely on grants alone. We need your help to build a thriving community and invest in more offerings for you. By making a recurring monthly contribution, you can play a vital role in supporting our mission. Every contribution, makes a significant impact. So, choose an amount that works for you, and feel the satisfaction that comes with knowing you are making a difference every month. You can modify your contribution at any time, and we welcome you to be a part of our community, regardless of your financial situation. Join us in building a brighter future together.Thank you for choosing PSILO Temple as your community. We look forward to embarking on a journey of growth, healing, and self-discovery with you.
Recurring Yearly Contribution
Spore Level - $330/year
Pinning Level - $605/year
Fruiting Level - $935/year
Mycelial Level - $1188/year
Together, we can achieve so much more than we ever could alone. While we are busy securing grant funding to support our mission, we cannot rely on grants alone. We need your help to build a thriving community and invest in more offerings for you. By making a recurring monthly contribution, you can play a vital role in supporting our mission. Every contribution, makes a significant impact. So, choose an amount that works for you, and feel the satisfaction that comes with knowing you are making a difference every month. You can modify your contribution at any time, and we welcome you to be a part of our community, regardless of your financial situation. Join us in building a brighter future together. Thank you for choosing PSILO Temple as your community. We look forward to embarking on a journey of growth, healing, and self-discovery with you.
One-Time Fee - $44
This helps fund the welcome process and screening and also helps cover administrative costs, providing member benefits and supporting our mission.
Total includes $44 setup fee.
Your Transformative Healing Journey
Medical Liability Release Form
Volunteer Sign-up Form
PSILO Temple Fundraiser