FEAT APPLY Copy | Awake.net

"*" indicates required fields

1. FEAT applicant's name*

First Last

2a. Your relationship to applicant?

Myself

Friend

Family Member

Doctor or Other Professional

2b. Your name if you are applying on behalf of someone else

First Last

3a. Applicant's Date of Birth*

4. Email Address (main point of contact)*

5. Phone*

6. Country of residence*

7. State and Zip Code*

8. Preferred way to contact you?*

Phone Call

Text

9. What's your main reason for applying for the FEAT grant?*

10. Please write your Life History in the box below.*

Write about where you have lived, major turning points in your life, and anything else you feel is meaningful.

10. Please write a detailed Medical History starting from conception to your current age. In particular list any pre-existing heart, lung, liver or other medical conditions that you know of?*

Please be detailed and honest as certain pre-existing conditions can cause heart failure during ibogaine treatment if not known and monitored closely. People in substance-abuse often minimize or conceal health problems or drugs in their system because they are so eager to get treated but we don't advise you do that, it could prove fatal. We don't judge you, and the more details we have the better we can prepare and guide you through the journey.

23.Do you have any current health conditions or Co-morbidity diagnosis?

Yes

11. Do you currently consume any of the following substances:*

Prescription Medications

Non Prescription Drugs

Psychedelics - plant medicines or synthetics

Herbs, Plant Medicines, or Supplements

None of the above

11a. List substances and dosage for prescription, non-prescription, and psychedelic substances. Please use the + sign to add each medication on a separate line and mention LENGTH OF USE, ROUTES OF ADMINISTRATION, # OF OVERDOSES

List EVERYTHING you are currently taking, prescription and otherwise, as some medications can have an adverse reaction with ibogaine and must be discontinued in a precise detox protocol prior to treatment under the guidance of an experienced provider.

12. Have you ever been diagnosed with a mental illness?*

List all diagnoses and year

13. Do you have an ongoing relationship with any of the following professionals (check all that apply)*

14. If you checked any of the above please say a little more about how long, how often, and for what reason you see them

15. Please upload a photo or video of yourself

Max. file size: 500 MB.

16. Do you currently have a regular source of income?*

Yes

17. Please enter the monthly income

16. If no, please briefly describe how you currently support yourself.

17. Do you have a valid Passport?*

Yes

18. Is there any reason why you WOULD NOT be able to get a passport?

Yes

18a. If you answered yes please briefly describe what the problem is

19. Please check all that apply

What is your intention as you go into this program? Please write a sentence or paragraph about it.*

20. FEAT APPLICANT AGREEMENTS*

I agree to raise $2000 of the total amount required to pay for my enrollment in the Nine Month Integration Program and kickoff the crowdfunding campaign.

I agree that it is my intention and responsibility to raise these funds by reaching out to my network. FEAT will assist me by helping create and promote the crowdfunding campaign through the Awake platform as well as trying to obtain discounts from ibogaine treatment providers, detox experts, integration providers and other healers and doctors.

I understand that my intention to heal is the most important ingredient, and I attest that I am NOT doing this to please someone else.

I agree that I will volunteer 120 hours of my time to the FEAT FRIEND volunteer program after my ibogaine reset.

I understand that if I do not properly follow the detox and precare protocols I may not be able to do the ibogaine treatment and could lose my spot.

I promise to attend the entire nine-month online Change Your Character program and be dedicated and diligent in my approach to this FEAT journey

21. Would you be willing to be documented on camera as a part of the FEAT grant, Iboga Saves documentary or Awake.net blog series?*

YES

I'M NOT SURE

NOTE: THIS IS NOT A REQUIREMENT AND YOUR ANSWER WILL NOT AFFECT YOUR CHANCES OF GETTING FEAT FINANCIAL AID. We are collecting stories about the journey of addiction, and the journey of addiction recovery with ibogaine, both the inner and outer journey. We feel that it is important to de-stigmatize addiction and addicts in the eyes of the general public. Through our first person mini-documentaries people can learn the details and best practices of how to prepare for ibogaine by watching someone else go through the process of preparation, travel, ibogaine treatment, and finally integration. All four steps are super-important. Our culture has been conditioned for many years to fear psychedelics, but new research is emerging everyday about the powerful and vital role that psychedelic medicines play in our physical, psychological and spiritual health, and major academic institutions are opening departments to research these mind-manifesting molecules. However because all research and medical use has been suppressed in most Western cultures since the 70's, there is still very little medical data or research available about ibogaine. Unlike other psychedelics, ibogaine can be fatal if taken under certain cardiac conditions or in the presence of other contraindications, both known and unknown. In the absence of medical research, these anecdotal narratives will play a vital role in educating the mainstream. Please browse the blogs on https://blogs.awake.net to learn more about ibogaine, and read the https://awake.net/safety page to learn more about risks. And most important: Do your own research.

21a. MEDIA CONSENT & RELEASE FORM

I, for myself and on behalf of my heirs, successors, and assigns, hereby irrevocably and perpetually grant to Lakshmi Narayan and Eric Thiermann (the “Producers”) his/her heirs, executors, licensees, successors and assigns:

My consent and the right to use any original footage of me taken by myself or others for the purposes of the FEAT Program or the Iboga Saves documentary to end the opioid epidemic. The footage may be used in connection with a social media campaign and motion picture film (and all the versions, adaptations and trailers thereof) tentatively entitled IBOGA SAVES (the ‘Campaign’) and Root to Liberation (the “Picture”) and all advertising and publicity relating thereto and all transcripts and derivative versions thereof.

My consent and the right to project, exhibit, broadcast and exhibit in any and all media of any and every nature whatsoever now known or hereafter devised, said photographs, likenesses, images, and recordings and other reproductions of my voice, in or whole in part, in connection with the Picture (an all versions, adaptations and trailers thereof) and all advertising and publicity relating thereto and all transcripts and derivative versions thereof.

My consent and the right to copyright (in the United States and elsewhere) for the initial and any renewed or extended period or copyright, in such name as Producer may elect, the picture (and all versions, adaptations and trailers thereof), all advertising and publicity relating thereto, all transcripts and derivative versions thereof and all said photographs, likenesses, images, and recordings and other reproductions of my voice.

I hereby agree that the Producer and his heirs, executors, licensees, successors and assigns may exercise all or any of the rights herein granted by me without claims, demands or causes of action at law or in equity, whether for libel, defamation, violation or right or privacy, or infringement of any literary or other property right or otherwise, insofar as I, my heirs, successors, and assigns are concerned,

I the undermentioned FEAT applicant accept and agree to be documented and grant you rights to use my footage as named above.

22. WAIVER OF LIABILITY*

WAIVER AND RELEASE OF LIABILITY

IN CONSIDERATION OF the risk of injury that exists while participating in IBOGAINE TREATMENTS FOR ADDICTION THROUGH AWAKE.NET'S FEAT PROGRAM (hereinafter the "Activity"); and IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;

I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this
WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and I HEREBY release and forever discharge AWAKE.NET'S FEAT PROGRAM, located at 1228 University Ave, San Diego, California 92103, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize awake.net's FEAT
program to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially
responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the awake.net's FEAT program official or agent, regarding my approval to participate in the Activity.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE awake.net's FEAT program AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND
ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A
LEGAL ACTION AGAINST awake.net's FEAT program FOR PERSONAL INJURY OR PROPERTY DAMAGE.

To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of awake.net's FEAT program, its agents, and Employees.

I agree that this Release shall be governed for all purposes by California law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.

In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.

THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL
SUBSEQUENT EVENTS OF PARTICIPATION.

THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both FEAT applicant, and awake.net's FEAT program agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall
remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. In the event of an emergency, please contact the following person(s) in the order presented: Emergency Contact Contact Relationship Contact Telephone

I, THE UNDERSIGNED FEAT APPLICANT, AFFIRM THAT I AM 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

I, the undermentioned FEAT Applicant agree to the waiver of liability

22a. Waiver of Liability Signature*

First Last

23a. please describe. Special focus concerning heat, lung and liver, any history of seizures or serious brain injury conditions?

23b. Are you receiving treatment for any current health conditions?

23. Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

24. Is this application for a minor?*

If you answer Yes please fill out waiver below.

Yes

25. PARENT / GUARDIAN WAIVER FOR MINORS

In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian.

Minor first name Minor last name

26. Parent or Guardian's Name

I HEREBY CERTIFY that I am the parent or guardian of the person named below, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

First Last

27. Relationship to Minor

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