FEAT Application | Iboga Saves: A Movie and a Movement

FEAT Grant Application

Dear Friend: This grant provides travel, treatment, and integration funds to opioid addicts seeking treatment with ibogaine or other entheogenic protocols. Grant amounts are determined on a case-by-case basis and range from $1,000 to $15,000 depending on what portion of it you can raise yourself. We require that you raise at least $1,000 of the total amount by your own efforts. The grants are disbursed directly to the ibogaine clinic and integration provider selected from the approved list of Providers. ABOUT IBOGAINE: Iboga/ibogaine is a psychedelic plant medicine that can interrupt opioid addiction in a single treatment without withdrawal. Ibogaine is called the "addiction interruptor" because it actually restores the physiology (receptors and brain neurons) to a "pre-addicted" state. When coupled with an integration aftercare program it can be a powerful medicine for the opioid addiction that affects body, mind, and spirit. It needs to be administered with clinical and therapeutic care and customized detox protocols depending on which cocktail of drugs, legal or illegal, the person might be on. Ibogaine also requires an aftercare integration plan in order for the "interruption" to become a permanent thing. As one clinic owner says: "You have to change one thing: Everything." ABOUT FEAT: Because ibogaine is classified as a Schedule One drug with "no medicinal value" it is off limits in the US and Canada, the home of the opioid epidemic. Many clinics have sprung up in Mexico, Europe, Africa, New Zealand, and elsewhere to treat opioid addiction with ibogaine. However, because it's not covered by insurance in the US/Canada, people cannot afford the cost of travel, treatment, and integration. Hence this grant. The FEAT grant was created as a part of the Iboga Saves campaign to end the opioid epidemic by Awake.net, a non-profit pending 501c3 corporation. To learn more visit https://ibogasaves.awake.net

1. FEAT applicant's name*
First Last
2. Your name if you are applying on behalf of someone else
First Last
2a. Your relationship to applicant?*
- Myself
- Friend
- Family Member
- Doctor or Other Professional
3. FEAT applicant's Date of Birth*
MM slash DD slash YYYY
3a. Is the applicant 18 years of age or older?*
- Yes
- No
4. Email Address (main point of contact)*
5. Phone*
6. Country of residence*
7. State and Zip Code*
8. Preferred way to contact you?*
- Email
- Phone Call
- Text
9. Do you have any pre-existing heart, lung, and liver conditions that you know of?*
Please be accurate as certain pre-existing conditions can cause heart failure during ibogaine treatment if not known and monitored closely. Addicts 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.
- YES
- NO
10. If you answered YES above please elaborate:*
11. Do you currently consume any of the following substances:*
- Prescription Medications
- Non Prescription Drugs
- Psychedelics
11a. If you answered YES above please list all substances:*
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 the treatment provider. Please use the + sign to add each medication on a separate line and mention if you take it 'daily' or 'sometimes'.
12. Have you ever been diagnosed with a mental illness?*
If the answer is YES please list the diagnoses below. Use the + sign if listing more than one item. If the answer is NO, simply state it in the box.
13. Please upload a photo or video of yourself
Max. file size: 256 MB.
14. FEAT APPLICANT AGREEMENTS*
- I agree that it is my responsibility to raise at least $2000 of the total costs by my own efforts
- I agree that within 3-6 months of my ibogaine treatment, I will volunteer 80 hours of my time to the FEAT FRIEND program to help other addicts ibogaine treatment and recovery.
15. 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
- NO
- 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://ibogasaves.awake.net/blog to learn more about ibogaine, and read the https://ibogasaves.awake.net/safety page to learn more about risks. And most important: Do your own research.
15a. IF YOU SAID YES ABOVE: 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 Iboga Saves campaign 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.
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
FEAT Applicants Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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
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
Relationship to Minor