TierraMítica Registration Form

Please complete this form on your computer and email it, including a scan of your passport page with your photo and a scan of the signed agreement of participation as attachments to info@tierramitica.com . Receipt of this completed form from your email constitutes agreement to all terms and conditions found at the end of this form.

Your 30% deposit or payment in full should be sent by bank transfer or Western Union. Bank details are below, or to use Western Union simply send payment to any Western Union Office in Tarapoto Peru, in the name of Michail Chason and email the transfer number (mtcn) to info@tierramitica.com .

If you send a deposit, full payment will be due on or before the first day of your stay. You may pay your balance in cash when you arrive in $US. Please bring only new bills, with no tears or writing on them. Old, damaged or crumpled bills are not accepted in Peru.

Our Address:

Jr. Bolognesi #274, Tarapoto Peru


Our Bank Account for Payment Transfers:

TierraMitica SAC Tarapoto Account number (UsDollar account) 323-7073486, Scotia Bank

Peru SAA, Av Dionisio Derteano 102, San Isidro,Lima Peru, Swift BSUDPEPL,

International Correspondent Bank (for bank use only) : Bank of New York, 1,Wall St., 19th

Floor New York City NY 10015 USA (ABA No.(not Swift) 021000018.

When sending a wire transfer to our bank, please ensure you send enough to cover all fees you incur. If you are at the bank, you may state you want to ensure we receive the full amount.

I have read the terms and conditions at the end of this form for participating in any program or retreat at TierraMitica Healing Center. I am fully aware that these programs may include deep cleansing through medicine plants and psychotropic plant medicine like “Ayahuasca”, traditionally used for healing and vision quests and that the intake of these plants may cause deep emotional and physical reactions, and that spiritual, emotional and physical changes and break-throughs may occur as part of the experience. I fully understand that the jungle is a natural environment and fully absolve TierraMitica S.A.C. of any liability and responsibility from any accidents that may occur in this environment. I declare that I abide by the terms and conditions and to behave in a responsible way to protect myself, the environment and the creatures and plants within it.

  1. Name(*)
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  2. Register for the Mythic Voyage:

  3. Mythic Voyage US$ 1,680
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  4. Your Info:

  5. Name(*)
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  14. Skype
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  15. Date of birth(*)
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  18. Profession
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  19. Emergency Contact(*)
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  20. Emergency Phone(*)
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  21. Meals(*)
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  22. Food Allergies or Intolerances
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  23. Special Food Issues
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  24. Medical Advice and Precautions

  25. Ayahuasca (Banisteriopsis caapi) contains monoamine oxidase inhibitors (MAOIs) in the form of harmine and harmaline. Please consult your medical advisor if you are taking medications which may affect your serotonin levels (known as serotonin selective re-uptake inhibitors or SSRIs) as the combination of MAOIs and SSRIs can lead to higher levels of serotonin in the body. SSRI medications generally require 4-6 weeks to clear the body and should be reduced gradually.You cannot take Ayahuasca or other medicine plants if you are taking anti-depressants. It is important to consult with your doctor if you are taking any medication in order to ensure that there are no counter indications, and any prescription or non-prescription medicine such as antihistamines, dietary aids, amphetamines and their derivatives and some herbal remedies (e.g. those containing ephedrine, high levels of caffeine or other stimulants) should be discontinued for at least a week prior to and following work with ayahuasca. Please check with your herbalist or homeopath as even otherwise harmless herbs like St John’s Wort may not be suitable in combination with ayahuasca. Avoid all chemically-based recreational drugs, in particular MDMA (ecstasy), cocaine, speed and heroin. Non-chemical recreational drugs such as marijuana and alcohol should also be discontinued for a period of at least one week before and after a retreat. Ayahuasca and the diet that goes with it are not always ideal in combination with certain medical conditions (e.g. some stomach, heart, or colon problems) so, again, please check with your doctor and take his or her advice about participation. It is especially important to declare in the Health Questionaire below any medical and health concerns and conditions you may have or have suffered from in the past. Please be very careful in declaring any Heart condition, including irregular heartbeat, arythmia or any other problems. We need to know everything so that we can protect you and support you. Please do not hesitate to declare any drug and addiction problems, our job is to help you, not to exclude you or judge you. It is also important to advise us of any mental issues including clinical depression, bi-polarism and even other, milder conditions. Everything can be healed with trust and intention, so please provide all relevant information so that we can help you. Please also start a cleansing diet as long as possible before your program, avoiding red meats, fats, sweets, all types of aged or cured foods, cheese, spices , ginger and of course, alcohol and drugs. Besides a healthy cleansing and detox, it will enhance your intention and determination. No vaccinations are mandatory or necessary for travel to Peru. Malaria is not an issue in Peru and Malaria pills will make you feel ill with no real benefit. Normal health precautions as in any other country are all that is necessary to enjoy Peru without any health issues, however the jungle is not an amusement park and responsible caution and behavior should be exercised at all times. Medicine plant intake is not allowed during pregnancy.



  26. Health Questionnaire (Confidential)

  27. Please advise if you have been diagnosed or are suffering from any of the following conditions: High Blood Pressure, Circulatory problems, Strokes or Thrombosis, Heart Attack or Heart Surgery, Aneurisms, Diabetes, Epilepsy, Infectious Disease, Schizophrenia or other Mental Disorders including Suicidal Tendencies and Bipolarism. Please provide details of any treatments for the above or any other serious medical problems or surgical procedures.
  28. Medical History
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  29. Are you taking currently any medication -If Yes, what , dosage details and for how long?
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  30. Do you have any Physical or other limitations or needs we should know about? If Yes, please specify
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  31. Have you taken Ayahuasca or other psychotropic plants, medicine or drugs in the past? If Yes, please specify what, where, when, how many times and under what conditions
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  32. Terms and Conditions

  33. “Participant” is the person named on the Registration form. “TierraMitica S.A.C.” is represented by its Managing Director and its Managers.
    1. TierraMitica S.A.C. reserves the right to accept or decline a Participant booking at any time. The Participant agrees to take part in a program or retreat at TierraMitica HealingCenter, including its plant ceremonies.
    2. TierraMitica S.A.C. will do its utmost to ensure the safety and comfort of the Participant within the remit of this program. The Participant, in turn, agrees to exercise caution and consideration for him or herself and for others during this event, including at the venue and in other environments, and indemnifies TierraMitica S.A.C. against claims for injury, loss, damage, misadventure or inconvenience at all stages.
    3. The Participant has made confidential disclosures regarding medical conditions and/or use of medications. The Participant declares that all such information is truthful and complete. TierraMitica S.A.C. agrees to keep these in confidence unless required by law to divulge them and/or for the resolution of any dispute. The Participant agrees to inform TierraMitica S.A.C. of any change in circumstances.
    4. TierraMitica S.A.C. has recommended that the Participant, prior to entry into this Agreement, seeks and obtains health or medical advice as to the effect of plants and herbal medicines singly and in combination with any medication they are taking. The Participant avows that they, having done so or deemed it unnecessary, is in a physical and mental condition appropriate to the activities described in this brochure and agrees to participate at their own risk. The responsibility for taking accurate and timely health precautions, professional medical advice, and for acting upon this (or otherwise) is solely with the Participant.
    5. The Participant has the option of joining any, all, or none of the activities on offer at TierraMitica Healing Center and taking any, all or none of the plants available, and should he or she wish to take them does so voluntarily, taking full responsibility for his or her actions.
    6. The Participant has been advised that ayahuasca is a visionary psychotropic plant and is clear on the meaning of this. Reference sources have been provided which may describe the ayahuasca experience and the Participant has conducted other research where appropriate to satisfy him or herself of the effects that may be produced. The liability is with the Participant.
    7. TierraMitica S.A.C. agrees to supply transportation, plant medicines, accommodation and food as part of this event during the dates given and within the guidelines supplied by each program, dieta or retreat. TierraMitica S.A.C. is not responsible for travel or other costs outside of this program or for flight cancellations or other interruptions or travel disruptions and no refunds, reimbursements or payments-in-kind will be made for these.
    8. TierraMitica S.A.C. reserves the right to make changes to the itinerary of this program if necessary or to cancel this event if need be. In the unlikely event that the program is canceled a full refund will be made to the Participant of fees paid by him or her to TierraMitica S.A.C. TierraMitica S.A.C. is not, however, responsible for other costs which the Participant may incur or have incurred such as transportation or the purchase of any goods or materials.
    9. TierraMitica S.A.C. will do its best to help with any special requests or needs that the Participant may make or have but are not beholden to do so and the Participant understands that such requests may need to be paid for by the Participant separately to this program and its contents and that he or she may also have to make his or her own arrangements (e.g. for travel outside the program) and at his or her own cost.
    10. If the Participant withdraws from this event the program or retreat fee will be refunded in full provided that his or her cancellation is made in writing and reaches TierraMitica S.A.C. before 60 days prior to the first day of the program, save for the Participant’s deposit which is non-refundable in all circumstances. TierraMitica S.A.C. is not responsible for any other costs which the Participant may incur or have incurred.
    11. The Participant will not hold TierraMitica S.A.C. liable for damages, injuries, losses, accidents or delays, including willful or negligent acts, failures to act or breaches of contract by any parties which supply goods or services for this event.
    12. The Participant indemnifies TierraMitica S.A.C. against loss or damage, including that resulting from insufficient or improperly issued passports, visas or other travel documents.
    13. The Participant is advised to take out suitable medical and travel insurance for their journey and this event, covering personal accident, medical expenses, losses, repatriation costs and all other expenses which might arise as a result of loss, damage, injury, delay or inconvenience. TierraMitica S.A.C. is not liable for such expenses.
    14. The Participant and their family understand that the Amazon rainforest and this program represent travel of a unique nature and will hold the TierraMitica S.A.C. and its associates, representatives and employees blameless for any injury or ailment occurring during this program or afterwards.
    15. The Participant agrees to show respect for the environment he or she is in and to act with courtesy and dignity towards other group members and local people at TierraMitica Healing Center . Should the Participant commit any illegal act or should their behavior adversely affect other people’s enjoyment of this event they may be asked to leave the Center and shall have no entitlement to complaint or refund.
    16. The relationship between the Participant and TierraMitica S.A.C. is governed by Peruvian law and in the unlikely event that a controversy arises which cannot be resolved between us both parties agree to the exclusive jurisdiction of the Peruvian Courts in Tarapoto, Peru.

    17.The Participant has read, understood and voluntarily signed this document and agrees that no representations, statements or inducements have been made by TierraMitica S.A.C. for him/her to take part in this program or to sign this Agreement. By signing the Participant waives certain legal rights, including the right to sue.




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