Booking Form

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Hummingbird Center Booking Form

Thank you for applying for an ayahuasca retreat at the Hummingbird Center! To begin our registration process, please fill out this form, and we will try to get back to you within 24 hours with any follow up questions we may have.

All information provided will be kept private and confidential.

Please be sure to have read our Ayahuasca Safety page.

For your own safety and well being, it is important the medical background and medication information be truthful and accurate. Certain conditions and medications have potentially serious risks when combined with ayahuasca.

Name

Age

Gender

City

State/Provence

Country

Retreat Program

Retreat Date

Discount Code

What led you to our website?

Please specify

Dietary Preference

Diet Restrictions

Reason for Retreat

Have you ever or are you currently suffering from any of the following conditions?

Asthma

Diabetes

Cancer

Bipolar disorder

Mental Illness

Schizophrenia

Anxiety

Depression

PTSD

IBS

High blood pressure

Low blood pressure

Medical History Background

Medical Conditions

Medications

Special Needs

Emergency Contact

Emergency Contact Email

Booking Agreement

I agree NOT to book flights or make travel plans until my application has been approved. I understand that my registration is not confirmed until my application has been reviewed and approved by the Hummingbingbird AND I have paid my deposit.

Payment Agreement

I understand that a minimum 50% deposit is required to confirm my booking or that I may pay the full retreat cost if I prefer. I understand full payment must be made at least 2 weeks prior to the start of the retreat to guarantee my space.

Cancelation Terms

I understand that if I cancel my registration more than 4 weeks prior to the start of the program I may transfer to a different program or transfer my payment to personal credit to be used within the next 2 years. I understand that I will not receive a refund. I understand that if I cancel my registration within 4 weeks of the start of the program I may only transfer to a different program or transfer my payment to personal credit to be used in the next 2 years if the Hummingbird can fill my place in the program

Terms & Conditions

I accept the full terms and conditions attest that all information is accurate and accept full legal & personal liability for joining this retreat protecting Hummingbird Center E.I.R.L. from all legal liability.

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Monitor Huascar #226
Iquitos, Peru
+51 982 820 757

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