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The Living Church


By signing below, I affirm and declare that all of the following statements are true and correct:

I am 21 years of age or older.

I am of sound mind and body.

I have read and agree with the sacred teachings contained in the holy text(s) of The Living Church

San Francisco, Inc. (the “Church”).

I agree to abide by the rules, regulations, and safety standards set forth by the Church, and any

updates thereto.

I am aware that the Church’s religious worship requires the use of the Holy Sacrament of entheogenic

fungi including mushrooms from the Genus psilocybe, which are ingested with the religious intent of

producing a non-ordinary state of consciousness and enabling religious connection with the Divine. I

believe in good faith that entheogenic fungi are the Church’s Holy Sacrament, and are a gift from the

Divine.

I believe in good faith that I cannot practice my religion without the Holy Sacrament.

I agree to use the Holy Sacrament only for religious purposes.

I agree to never use the Holy Sacrament for unholy purposes; non-religious use is forbidden because

it is a desecration of the Holy Sacrament.

I hereby agree that the Church may assert all of my rights and freedoms pursuant to the United States

and California Constitutions and applicable laws, including but not limited to, the Religious Freedom

Restoration Act.

I do not currently work for any law enforcement agency.

I agree to treat as confidential any information I learn or obtain through my involvement with the

Church, including the contents of this document.

I agree not to take, post or publish photographs of, or statements about, the Church, its teachings, its

locations, or its religious activities without written permission from the Church.

I swear that all of the information I have provided and will provide to the Church is true.

I have been given enough time to read all documents, as well as an opportunity to consult with my

own medical and legal professionals, prior to signing.

I declare under penalty of perjury under the laws of the United States and the State of California that all

of the foregoing statements are true and correct, and that this declaration is executed at San Francisco,

California on the date set forth below.

Dated: ______________ Signature: ______________________________

Print Name: ______________________________

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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