Mama Killa World (MKW) — Spiritual/Educational & Wellness Activities (Non-Medical)
Version: 1.0 Last updated: 15/10/2025
Please read carefully. This document explains what MKW offers, how to prepare, potential risks/contraindications, how we protect your data, and your legal acknowledgements. Complete all sections truthfully. If something does not apply, write “N/A”.
Full name: _______________________________
Date of birth (18+ only): ____ / ____ / ______
Phone (reachable during the event): __________________
Email: _______________________________
Emergency contact (name & phone): _______________________________________
City/Country of residence: _______________________________________________
MKW facilitates spiritual/educational and wellness practices (e.g., circles, meditation, breathwork, chants/sound, non-controlled herbal baths, ice bath, educational integration, and specific traditional practices listed below).
MKW does not provide medical, psychological, or psychiatric care.
MKW does not diagnose or treat disease, and does not advise starting, stopping, or modifying medication.
Practices may coexist with your professional care; they do not replace it. For doubts or health changes, you agree to consult your physician.
Any ceremony involving visionary plants/controlled substances is only considered where legally permitted; otherwise MKW does not announce or offer them.
Each practice/medicine has its own purification process.
You agree to follow the Practice-Specific Preparation Guide provided by MKW (before/during/after).
Duration and details vary by practice/medicine (in some cases up to a week or more).
The diet may include:
Abstinence from alcohol and recreational drugs.
Avoidance of foods/substances that may interact adversely or hinder the process (e.g., very heavy meals, certain stimulants).
You agree to arrive well-rested, responsibly hydrated, and on time.
You understand that not following preparation guidelines increases risk and may lead MKW to postpone or decline your participation.
Current medications (name & dose; include antidepressants/antipsychotics, MAOIs, SSRIs/SNRIs, benzodiazepines, beta-blockers, diuretics, anticoagulants, etc.): __________________________
Medical conditions (cardiac/vascular, hypertension, neurological incl. seizures, endocrine, renal/hepatic, respiratory, eye disorders such as glaucoma, bleeding disorders): _____________________
Mental-health history (diagnoses, hospitalizations, current therapy): _____________
Recent surgeries / injuries / active infections: ___________________________
Allergies/sensitivities (drugs, foods, plants, latex, etc.): ________________
Pregnancy/breastfeeding or intention to conceive: _________________________
Substance use (alcohol, tobacco/nicotine, recreational drugs): ______________
I confirm the above is true, complete, and up to date, and I will notify MKW of any changes.
Signature: _____________________________ Date: ____ / ____ / ______
These lists are preventive and not exhaustive. MKW may ask for clarifications, medical clearance, or decline participation for safety.
Potential risks: cold shock, dizziness, increased heart rate/blood pressure, hypothermia.
Avoid / use caution with: severe cardiovascular disease, arrhythmias, uncontrolled hypertension, severe Raynaud’s, prior hypothermia, high-risk pregnancy.
Contains nicotine; may raise blood pressure/heart rate; may cause nausea or dizziness.
Avoid / use caution with: uncontrolled hypertension, arrhythmias, pregnancy/breastfeeding, active severe migraine, recent nasal/sinus surgery.
Expected effects: intense transient burning, tearing, temporary blurry vision.
Avoid / use caution with: glaucoma, eye infections, recent eye surgery. Remove contact lenses; do not drive immediately after.
Potential risks: intense nausea/vomiting/purging, hypotension, brady/tachycardia, electrolyte imbalance (incl. hyponatremia if water intake is excessive), edema, rare severe complications.
Strictly contraindicated in: pregnancy/breastfeeding; cardiac disease/arrhythmias; aneurysms; organ transplant; decompensated psychiatric disorders; significant renal/hepatic disease; uncontrolled diuretic/antihypertensive therapy.
Preparation highlights: 8–10 h fasting (only guided water intake); strictly follow hydration limits and facilitator instructions.
Addendum required: you must sign the Kambô Addendum (specific warnings & aftercare).
Typical use: non-visionary (tea/tincture).
Avoid / use caution with: pregnancy/breastfeeding; anticoagulants/low blood pressure. Discontinue if reactions occur.
May contain indole/tryptamine psychoactives; only considered where clearly permitted, with reinforced screening, specific consent, and trained facilitation.
MKW may decline without further explanation for safety/compliance.
MKW does not publicly announce or offer controlled substances.
Any retreat with visionary plants is only considered when and where legally permitted, with local legal counsel, reinforced protocols, and specific consent.
Availability varies by jurisdiction and does not constitute an offer everywhere.
Follow facilitator instructions; respect group boundaries and confidentiality.
No access if intoxicated or under the influence of substances.
No recording/photographing others without explicit permission.
MKW may postpone, pause, or decline participation for:
Safety risks to you or the group,
Non-compliance with preparation or on-site rules,
Incomplete/incorrect information.
MKW facilitators are trained in basic first aid.
In adverse events, MKW may suspend the activity, provide initial care, and contact medical services.
You consent to emergency care/transport if needed and to sharing relevant information with responders.
MKW documents incidents and provides aftercare guidance and referrals where appropriate.
Purpose: assess eligibility, prevent risks, manage consents/incidents/referrals.
Data (minimum): identification/contact; self-declared conditions/medications; consents; safety notes/incidents.
Legal basis: your consent + MKW’s legitimate interest in safety/compliance.
Retention: forms/consents up to 2 years from last activity; incidents up to 5 years or as required by applicable rules.
Access: restricted to staff who need it; reasonable confidentiality and protection measures.
Sharing: no sale of data; shared only with emergency services, healthcare professionals (if referred), insurers, or authorities when required by law.
Rights: access/rectification/erasure where applicable; restriction/objection; withdrawal of consent (non-retroactive).
Privacy contact: info@mamakillaworld.com (subject: “Health & Safety – Privacy”).
Minors: MKW does not serve minors under 18 and does not collect minors’ data.
Select one (check one):
☐ I consent to be photographed/filmed/recorded, and for MKW to use my image/voice/testimony for informational or promotional purposes (non-defamatory use; first name only or anonymized upon request).
☐ I do not consent to any media capture or use of my image/voice/testimony.
If you consent, how should MKW refer to you? __________________________________
MKW does not promise results or cures.
Every person is unique; processes and outcomes can vary widely.
We believe meaningful change begins within each person and requires personal commitment.
Testimonials reflect personal experiences and do not guarantee outcomes for others; they are shared for informational/inspirational purposes, not as medical advice or efficacy claims.
MKW avoids language that could be read as medical advertising or therapeutic promises and states limitations/precautions where appropriate.
Assumption of risk: I acknowledge that these practices can involve physical and emotional risks; I participate voluntarily and assume such risks.
Release: to the extent permitted by law, I release MKW, its team, and collaborators from claims arising from my participation, except for willful misconduct or gross negligence.
Indemnity: I agree to indemnify and hold MKW harmless from third-party claims resulting from my breaches or omissions.
Legal compliance: I understand MKW operates according to applicable laws in each location and that availability of certain practices depends on local permissions/protocols.
Dispute resolution: we will first seek an amicable solution; if not possible, the jurisdiction/law applicable will be that of the activity’s location.
Updates: this consent may be updated due to best-practice or regulatory changes; I will be informed of the current version.
Severability: if any clause is held invalid, the remaining provisions remain in effect.
I have read this Informed Consent & Assumption of Risk, understand its contents, and agree to participate under these terms.
I confirm my answers are truthful, and I will follow the Preparation Guide for my chosen practice/medicine.
Name & signature: ________________________________________
Date: ____ / ____ / ______
Place: _________________________________________________
