New-Membership Application

Centro Espiritualista Luz Do Vegetal Church Inc.

New member application

Welcome to our community! Thank you for your interest in joining Centro Espiritualista Luz Do Vegetal Church Inc. Please complete the following application. This will take approximately ~25 mins.

The purpose of this application is to better understand prospective members to CELDV and their needs. Please express yourself honestly and include additional details as needed.

Privacy & Data Protection Notice

The information you provide in this application is collected solely for the purpose of determining eligibility and ensuring your safety in participation with Centro Espiritualista Luz Do Vegetal Church Inc.

Your responses will be treated as strictly confidential and accessed only by authorized Church leaders and facilitators involved in the discernment and admission process.

All records are stored in encrypted and password-protected systems, and will never be sold, shared, or disclosed to any outside entity except as required by law.

You may request to review, correct, or delete your personal information at any time by contacting privacy@celdv.org

By submitting this form, you consent to the collection and use of your information as described above.

1. First & Last name

2. Age

3. National Origin

4. City, State, Country of Residence

5. Phone Number

6. Occupation (job title and description):

7. What languages do you speak at a conversational level or higher?

8. Full name of the member who referred you:

9. Your relationship with the member who referred you:

10. What do you know so far about our spiritual institution?

11. What do you know so far about our sacrament (ayahuasca)?

12. Why do you want to attend our church ceremony and what do you intend to achieve by participating?

13. Have you ever participated in a ceremony before? If yes, please explain where and with whom. How many times?

14. Do you practice any type of sport, martial art or physical activity?

15. Have you served on active duty or are you a veteran in the Armed Forces of the United States or any other country?

Important note: ⚠️ False or misleading answers to the following questions may result in a severely dangerous medical situation by drinking Ayahuasca. If you answer “yes” to any of the following questions, please provide pertinent details. ⚠️

16. Do you have trouble sleeping? If the answer is positive, since when have you been experiencing difficulties with sleep?

17. Do you have friends? Who takes care of you when you're feeling down? Who is your best friend?

18. When you spend time with friends or family, how often do you truly enjoy the moment? Always, Almost always, Sometimes, Rarely, Never?

19. Do you hear voices? If so, please explain.

20. How do you deal with difficult situations?

21. Have you had difficulty with memory, concentration or attention?

22. Do you agree with the following statement: I am a narcissistic person? If so, please explain.

23. Do you often feel that others are watching you?

24. Do you feel that someone wants to control you?

25. Do you often feel alert?

26. Are you currently suffering from any behavioral addiction? If so, please explain.

27. Are you currently suffering from any food addiction?

28. Are you currently suffering from any pornography addiction?

29. Are you currently suffering from any addiction with the Internet, video games, etc.?

30. Have you ever suffered from panic attacks?

31. Have you ever used or do you currently use any recreational drugs or medications that were not prescribed to you? If yes, please list each substance, and the date of last use?

32. Are you currently dealing with any substance abuse, dependency, or addictions? If so, please explain.

33. Have you suffered from bipolar disorder, personality disorder, schizophrenia, psychosis, other mental disorders?

34. Have you suffered from epilepsy, seizures or stroke? If so, please explain.

35. Have you strongly considered or attempted suicide?

36. Have you ever been in a coma? If so, please explain.

37. Have you suffered an accident where you have had a fracture or injury to your head?

38. Are you currently under a doctor’s care? a psychologist, a psychiatrist, etc. If so, please explain.

39. Do you currently have or have had any health issues such as heart disease, blood pressure issues, liver or kidney disease, diabetes, glaucoma, or any previous surgeries etc.?

40. Are you currently taking any prescription medications or have you taken any within the last 12 months? If yes, please list each medication, why you are/were taking it, and the date of last use?

41. Have you ever taken any antidepressant medication? If yes, please list each medication and the date of last use.

42. Do you have any other medical conditions not addressed above?

43. Has anyone in your family suffered from bipolar disorder, multiple personality disorder, dissociative identity disorder, schizophrenia, psychosis, other mental disorders, epilepsy, or attempted suicide?

44. Are you currently suffering from any infectious or contagious diseases?

45. Are you currently receiving therapy or attending any kind of support group?

Please read this important information and submit the following forms. Click on each link.

https://www.celdv-usa.org/informed-consentand-release-form

https://www.celdv-usa.org/member-code-of-conduct

Acknowledgment & Consent

I understand that the purpose of this application is to ensure my safety and readiness to participate in the spiritual activities of Centro Espiritualista Luz Do Vegetal Church Inc.

I confirm that all information provided is accurate and truthful to the best of my knowledge. I understand that participation in any ceremony is voluntary, and that CELDV does not provide medical or psychological treatment or advice.

I agree and consent.

Your safety is important to us. To uphold our safety standards, please upload a valid government-issued photo ID, such as a driver’s license or passport.

Signature

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