The Mission Within
Waiver and Release of Liability

WAIVER OF RIGHTS

I, the undersigned participant, am executing this Waiver of Rights and Release of Liability as of today’s date marked below in favor of The Mission Within, LLC (doing business as “The Mission Within”), a Texas Limited Liability Corporation, and its members, managers, directors, officers, affiliates, employees, volunteers, successors, assigns, and agents (collectively, the “Mission Within”).

I, the undersigned, accept the conditions of participating in plant medicine sessions held by The Mission Within, and I declare that I am choosing to participate of my own free will. I have not been coerced into participating in sessions by the organizers or by any other person; the decision to participate is mine alone, and is based on my own personal assessment of the effects, the exclusion criteria, the potential risks and benefits, the focus of the session and the commitment of the people running it.

TREATMENT AND ENTHEOGENS

I understand I will receive treatment that includes plant medicines including but not limited to Ibogaine, 5-MeO-DMT, and/or psilocybin (the “entheogens”) and counseling (all together, the “Treatment”).

Ibogaine: An alkaloid derived from the root bark of the African shrub Tabernanthe Iboga or the Voacanga plant. Ibogaine is a restricted drug in the United States; religious use of entheogens is protected under the Religious Freedom Restoration Act.

5-MeO-DMT: A psychoactive indole alkylamine that can be found naturally in plants and the poison of the Bufo Alvarius toad, and it can be produced synthetically. 5-MeO-DMT is also a potent neurotransmitter produced inside the human brain. 5-MeO-DMT is a restricted drug in the United States; religious use of entheogens is protected under the Religious Freedom Restoration Act.

Psilocybin: The psychoactive compound found in Psilocybe and other genera of naturally occurring mushrooms. Psilocybin is a restricted drug in the United States; religious use of entheogens is protected under the Religious Freedom Restoration Act.

RELEASE

By signing this Release, I am confirming that I have read this Release prior to the treatment and understand the nature and risks of participation.

I confirm that I can decide whether or not to participate in a free and informed manner.

I am aware that I can ask questions about the session at any time and can change my mind about attending at any time before the session begins. Once the session has started, I commit to not leaving the space without the consent of the person running the session, and I commit to following the instructions always, from the preparatory stage through to integration.

I confirm that I am of sound mind and body to sign this Release.

I confirm that the Mission Within reserves the right to refuse my participation in any part of the treatment. I understand and agree that I can be excluded from participation in a session at the discretion of the facilitator.

I am aware that I am to answer all questions honestly during the screening process and am required to complete questionnaires before and after the session.

I agree to provide all the relevant information about my medical history, my mental and physical health and any other information that may serve to protect my health during this process.

AGREEMENT TO TERMS OF PARTICIPATION

I am voluntarily participating in this treatment and I am over the age of 18.

I hereby state that I currently have no physical illness or serious psychiatric disorder.

I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular trac, consumption of plant medicines including but not limited to Ibogaine, 5-MeO-DMT, and psilocybin, lack of hydration, excessive hydration and actions of other people including, but not limited to, participants, volunteers, monitors, and producers of the activity. These risks are not only inherent to participants, but are also present for volunteers.

I have been informed that taking the entheogens in conjunction with psychotropic and other drugs/supplements is dangerous, hazardous, and can cause life-threatening symptoms, so I agree not to take any medication or drug before, during, or after the treatment that has not been already approved by our medical staff.

I understand that once treated with the entheogens, I will be more sensitive to narcotics and taking narcotics may cause medical endangerment, including death.

I confirm that I will not use any illicit substances prior my arrival to the treatment. I confirm that I will not bring illicit substances or paraphernalia to the facility. I am aware that the staff may inspect my belongings and myself at any time, and I consent for them to do so. I am aware that I may be asked to complete a drug screening test onsite during the day of treatment to ensure that no contraindicated substances are present in my system, including alcohol.

I agree that after I am discharged I will seek medical attention if health issues arise and I will follow through with an aftercare program.

I understand and agree to be monitored during the necessary time frames for the treatment.

I understand that I cannot consume any solid food 3-6 hours before taking the entheogens although I can have liquids such as water or fruit juice (barring grapefruit juice).

COMMON EXPERIENCES

I understand that the lists below suggest common experiences reported from those consuming the entheogens and that these are in no way a comprehensive list of side effects of each entheogen. I agree to do my own research and elect to participate in the treatment of my own free will.

IBOGAINE:

Nausea and movement-induced vomiting.
Ataxia (impaired motor coordination).
Visual distortion.
Decreased need for sleep for several days after ibogaine administration.
Restlessness (which can last several hours).
Impairment in concentration and verbal communication (usually experienced during the first 6-8 hours of the experience).
I understand that all these side effects are transitory, and usually wear off completely after 24-36 hours, although the reduced need for sleep can last for several days.
I am aware that Ibogaine can bring repressed memories and emotions to the surface.
While these experiences are described by most people as profound and beneficial, to some individuals, they may be frightening and may produce anxiety and confusion. By signing this Release, I hereby indicate my understanding and acceptance of the risks of anxiety and confusion which may be caused by ibogaine ingestion.

5-MeO-DMT:

Visual distortion.
An immediate onset within seconds of inhaling.
Entering other dimensions even if your consciousness stays present in the room
Feeling a blast off into infinity and divinity.
Seeing only darkness or sacred geometrical shapes.
Seeing visions, images, memories, or future moments (but not usually).
Transcendence beyond awareness.
High energy frequencies pulsating through your body.
The feeling of weightlessness, like you are flowing and connected to divine energy
Impairment in concentration and verbal communication (usually experienced during the first hour of the experience).

PSILOCYBIN:

Visual distortion.
Typically a 20-60 minute onset.
Entering other dimensions even if your consciousness stays present in the room.
Seeing darkness or geometrical shapes.
Seeing visions, images, memories, or future moments.
Transcendence beyond awareness.
High energy frequencies pulsating through your body.
The feeling of weightlessness, like you are flowing and connected to divine energy.
Impairment in concentration and verbal communication.

PARTICIPANT DATA CONFIDENTIALITY AND MEDIA RELEASE

Care will be taken to preserve confidentiality of all information obtained from this treatment. My identity will not be revealed in any way unless I specifically give permission by my consent. My signature of this Release specifically does not grant the staff or any of their agents, employees, consultants, or other paid or unpaid assistants to reveal my identity to any other person, institution, or agency.

I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or my likeness to be used for any legitimate medical purpose by the activity holders, medical team, producers, sponsors, organizers, and assignees. I agree if I do not want my picture to be used at all I will let the Mission Within and its organizers know in a written statement.

AGREEMENT TO RELEASE FROM LIABILITY

I understand that side effects or harm can be caused by participation in the treatment. I understand that even with the use of high standards of care, side effects or harm could occur during this treatment through no fault of mine or the staff involved.

I desire to participate in the treatment. In consideration and exchange for being allowed to participate in the treatment, I hereby freely, voluntarily, and without duress execute this Release and agree to the following terms:

Assumption of Risk. I am aware and understand that the treatment may be inherently dangerous and may expose me to foreseen and unforeseen hazards and risks. I acknowledge that I am voluntarily participating in the treatment and have considered those hazards and risks. I hereby expressly and specifically accept and assume such hazards and risks, including any and all risk of injury, harm, loss, or death that I may incur as a result of my participation in the treatment.

Medical Treatment. I hereby give consent and authority to the Mission Within to obtain medical treatment on my behalf if I am injured or require medical treatment during my participation in the treatment. I understand and agree that I am solely responsible for all costs related to such medical treatment, medical transportation, and evacuation. I acknowledge that any injuries that I sustain may be compounded by negligent emergency response or rescue operations of the Mission Within or others. I hereby release, forever discharge, and hold harmless the Mission Within from any claim whatsoever in connection with such treatment or other medical services.

Release and Waiver. I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS Mission Within and its ceremonies, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous activities or defective equipment or property owned, maintained, or controlled by them, from my consuming of Ibogaine and 5-MeO-DMT, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared for participation in this treatment, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems or on any medications which preclude my participation in this activity. I acknowledge that this Waiver and Release of Liability Form will be used by the Mission Within, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity. I hereby fully and forever release and discharge the Mission Within from, and expressly waive, any and all claims (including negligence claims), demands, expenses, lawsuits, and any other liability of whatever kind or nature, either in law or in equity, of or to me, my property, or any other person, directly or indirectly arising from or in connection with my participation in the treatment. I covenant not to make, initiate, or bring any such claim, lawsuit, court action, or other legal proceeding or demand against the Mission Within, nor join or assist in the prosecution of any claim for money other or damages which anyone may have, on account of injuries (including death), losses, or damages, sustained by me, other parties, or my (or others’) property in connection with my participation in the treatment, and I waive any right I may have to do so. I fully and forever release and discharge the Mission Within from liability under such claims or demands. I UNDERSTAND THAT THIS RELEASE DISCHARGES THE Mission Within FROM ANY LIABILITY OR CLAIM THAT I MAY HAVE AGAINST THE Mission Within WITH RESPECT TO ANY ACCIDENT, BODILY INJURY, EMERGENCY TREATMENT, PERSONAL INJURY, ILLNESS, DEATH, PROPERTY DAMAGE, PROPERTY LOSS, OR RESCUE OPERATION THAT MAY RESULT FROM THE treatment, WHETHER CAUSED BY THE ACTIONS, INACTIONS, NEGLIGENCE, OR OTHER FAULT OF THE Mission Within OR OTHERWISE. I waive my insurers’ right to make a claim against the Mission Within based on payments by insurers to me or on my behalf for any reason, meaning my insurers have no right of subrogation against the Mission Within.

Insurance. I UNDERSTAND THAT THE Mission Within DOES NOT ASSUME ANY RESPONSIBILITY FOR OR OBLIGATION TO PROVIDE FINANCIAL ASSISTANCE OR OTHER ASSISTANCE, INCLUDING BUT NOT LIMITED TO MEDICAL, HEALTH, OR DISABILITY INSURANCE OF ANY NATURE IN THE EVENT OF MY INJURY, ILLNESS, OR DEATH, OR DAMAGE TO OR LOSS OF MY PROPERTY. I expressly waive any claim for compensation or liability on the part of the Mission Within in the event of any injury or medical expense.

Indemnification. I hereby agree to indemnify, defend, hold harmless, and reimburse the Mission Within from any and all actions, awards, claims, costs, damages, deficiencies, expenses, fines, interest, judgments, liability, losses, penalties, or settlements, including legal fees and the cost of pursuing any insurance providers, that it may incur or sustain as a result of my participation in the treatment, arising out of any third-party claim. I will reimburse the Mission Within if anyone makes a claim against the Mission Within in connection with my participation in the treatment, including, without limitation, any accident I may be involved in or any injury, loss, damage to me, other parties, or property, however caused.

Miscellaneous. I hereby agree that this Release represents the sole and entire agreement between the Mission Within and me and supersedes all other prior or contemporaneous agreements, representations, understandings, and warranties, both written and oral, between us, with respect to the subject matter hereof. If any term or provision of this Release or the application thereof to any party or circumstance shall be held to be invalid, illegal, or unenforceable to any extent by any court of competent jurisdiction, that term or provision shall be deemed modified so as to be valid and enforceable to the full extent permitted in that jurisdiction, and such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. The invalidity of any such term or provision shall be deemed modified so as to be valid and enforceable to the full extent permitted. This Release is binding on and shall insure to the benefit of the Mission Within and me and our respective heirs, executors, administrators, legal representatives, successors, and permitted assigns, and my spouse and next of kin, without limitation. Section headings are for convenience of reference only and shall not define, modify, expand, or limit any of the terms of this Release. The terms of this Release shall continue from this date forever. I have not withheld any information that would influence the Mission Within’s decision to allow me to participate in the treatment. I will follow any and all instructions, recommendations, and cautions

Governing Law. I hereby agree that this Release is intended to be as broad and inclusive as permitted, and that the words, terms, provisions, covenants, and remedies contained in this Release shall be governed by, interpreted in accordance with, and enforceable to the fullest extent permitted by applicable laws of the courts of California without reference to any choice of law doctrine, and I hereby consent to the exclusive jurisdiction of such courts.

PARTICIPANT’S AUTHORIZATION STATEMENT

I have read and fully understand the information in this release, and I am participating in this treatment freely and voluntarily.

By signing below, I acknowledge that I have read and fully understood all of the terms of this release and that I am voluntarily giving up substantial legal rights, including the right to sue the mission within, without any inducement, assurance, or guarantee being made to me. I completely and unconditionally release all liability to the greatest extent allowed by law.

The Mission Within Waiver and Release of Liability