NOVO TEMPO INTERNSHIP

Registration form / History

This questionnaire aims to find out a little more about you, your objectives in relation to
the ritual of using the sacrament and your state of health.

Last name and first name : Víctor Gomez

…………………………………………………………………………………….

Address : ……………………………………………………………………………………………..

Postal code and city :

……………………………07007 Palma…………………………………………..

Country:

……………España…………………………………………………………………………………
…
Civil status :
…………………single…………………………………………………………………

………..Number of children:

………………………………………none………………………………………….

Cellphone : …0034634385694………………….……………………………………………

……………
E-mail : …viktorgm90@protonmail.com…………………………………..

…………………………………………………………

Passport or identity number: ……………………………………………………………………

Profession: …administrative……………………………………………………………………

………………… ..Date of Birth : …26/11/1990………………………………………………

Contact name in case of emergency:
……………………………..

Nahuel (just spanish)………………………………………………………………

Contact mobile phone: …+34644370935…………………………………………

…………………… ..

Date of the 1st Novo Tempo course desired:….

………Friday and Saturday 7-8 april…………

……………………………… ..

Notice to participants

Carefully read the entire content of this registration form. After reading it completely, the
information provided will be analyzed and will serve as a basis for an individual interview,
and it is only on this condition that the person concerned will be authorized or not to
participate in the course.

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THE AYA TEA OR NIXIPAE

For reasons of discretion, we will use the word Nixipae to refer to Aya tea. This is the
name given by the Kaxinawa Indian people, Huni Kuin. There are many other names for
this same preparation: yagé, Uni, Daime….

It is the result of cooking a vine, often Banisteriopsis associated with a leaf, often
Psychotria Veridis.

Nixipae is used exclusively responsibly in the rite, respecting the principles of legality,
morality, religious freedom (of belief and worship), freedom of expression, thought and
creation, without association with any substance illicit psychoactive.

The religious use of this tea is recognized and protected by the Brazilian State by
resolution n ° 01 published in the Official Journal of the Union on January 25, 2010 of the
National Council for Drug Policy - CONAD. The tradition in Peru is classified as national
heritage.

Novo Tempo, is an organization that beneficially uses Nixipae as a sacrament and

entheogenic element, without any association with illicit psychoactive substances.

RESPONSIBILITY OF PARTICIPANTS

The participant must provide reliable information about his state of health in this form and
correctly note all the personal data requested.

THE RITUAL SAYS WORK

Participation in rituals must be motivated by a free and spontaneous will; the participant
must be aware of the effects provided by the use of Nixipae as an entheogenic element *
(including physical and health effects), of the rules of conduct and that it is an act of faith
and not a therapeutic procedure.

The word entheogen essentially means "inner manifestation of the divine". An

entheogenic substance ensures the expansion of consciousness. It allows us to perceive
more and better the reality of which we are a part. The opposite of a hallucinogen which
produces hallucinations, unreal perceptions and estrangement from reality.

Those who are unwilling or unable to stay until the closing date should not participate.

The participant will not use illicit psychoactive substances and will not carry any type of
weapon or sharp object in or near the work area.

Will the participant not use a phone camera or video camera without prior permission,
while working, or disclose the name or profession of the participants, or write to 'articles,
review or make reports that identify other participants.

The Participant must not drive a motor vehicle immediately after completion of the Works,
nor drink alcohol or any psychoactive substance (legal or illegal) during the works and
within 24 hours of their completion.

We will not be responsible for any negative consequences resulting from the participant's
irregular or illegal conduct or procedures after spiritual work.


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ANAMNESE

• What is your goal in participating in a ritual using the sacrament Nixipae…?

• What are you looking for in this ritual?

( ) Religion ( ) Self-knowledge ( ) Spirituality ( ) Curiosity ( ) Other………………………

Comment :

• Have you ever tried the Nixipae? ( ) Yes ( ) No

If so, where?

• Have you attended or are you attending any spiritual rites? ( ) Yes ( ) No

If yes which?

• Do you have some degree of psychic sensitivity? ( ) Yes ( ) No

Comment:

• Do you consume some kind of alcoholic drink? ( ) Yes ( ) No

If so, how often ?

• Are you using illegal drugs? ( ) Yes ( ) No

If so, what types of drugs? ………………………………………………………………………

How frequently ? ……………………………………………………….………………………….

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• Do you have other relevant information?

• Do your loved ones know that you will participate in this ritual? ( ) Yes ( ) No

Comment :

• Who invited you to participate in Novo Tempo? ………………………………………………

• How long have you known this person? ……………………………

• What is the degree of kinship or friendship with the person responsible for your coming?

………………………………………………………………………..……………………………….

• Did he (responsible) advise you on the use of the sacrament, effects, house rules, drug
interactions, psychic effects, preparation before the ritual, etc. ? ( ) Yes ( ) No

• Do you still have questions to clarify?

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PARTICIPANTS 'HEALTH INFORMATION

The list of absolute and relative vetoes and the resulting medical restrictions on
participation in the ritualistic works of the Nixipae sacrament comply with the directives
contained in resolution no.01 published in the Official Journal of the Union of January 25,
2010 of National Council on Drug Policy - CONAD

Clarifications:

The combination of antidepressants with Nixipae interferes with the metabolism of

serotonin and can therefore lead to a picture of seratonin syndrome. The use of
tranquilizers, in turn, enhances the effect of Nixipae.

List of drugs, the use of which prevents participation or involves additional medical care.

The participant must mark with "x" which drugs he uses.

ABSOLUTE VETO

1. Users of antipsychotics (for schizophrenia / psychosis):

( ) Haloperido (Haldol)

( ) Chlorpromazine (Amplictil, Longactil)

( ) Neozin

( ) Risperidone (Risperdal, Risperidon)

( ) Olanzapine (Zyprexa)

( ) Ziprazidone (Geodon)

( ) Quetiapine (Seroquel)

( ) Clozapine

2. Users of mood stabilizers, who have bipolar disorder (absolute restriction due to
illness):

( ) Lithium (Carbolitium)

( ) Valproic acid (Dekene, Depakote, Valpakene)

( ) Carbamazepine (Tegretol, Tegrex)

( ) Oxcabazepine (Trileptal)

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RELATIVE VETO
Relative obstruction to the participation of the interested party

1. Users of antidepressants:
The participant may attend the work provided that, after medical advice, he has not used
the drugs specified below in the six (6) weeks preceding the date of the work.

( ) Fluoxetine (Prozac, Depress, Daforin, Fluxene)

( ) Sertaline (Zoloft, Assert, Tolrest)

( ) Venlafaxine (Venlift, Efexor)

( ) Citalopran (Cipramil, denyl, Procimax)

( ) Escitalopran (Lexapro)

( ) Paroxetine (Aropax, Pondera, Cebrilin)

( ) Tranylcypromine (Parnate)

( ) Moclobemide (Aurorix)

( ) Amitriptyline (Amitryl, Triptanol)

( ) Imipramine (Depramine, Imipra, Tofranil)

( ) Nortriptyline (Pamelor)

( ) Bupropion (Wellbutrin, Zetron)

( ) Remeron

2. Tranquilizer users
The participant can attend spiritual works provided that, according to the medical
opinion, he has not used the drugs specified below within 24 (twenty-four) hours
preceding the start of the ritual.

( ) Diazepan (Dienpax, Compaz, Valim, Calmociteno)

( ) Bomazepan (Lexotan, Somalium)

( ) Lorazépan (Lorax)

( ) Nitazepam (Sonebon, Nitrapan)

3. Systemic diseases
The participant will be able to attend spiritual works as long as there is a written medical
authorization, without hindering the following clinical situations:

Have heart disease Uncontrolled hypertension

Impaired health

High risk pregnancy

Severe systemic diseases

4. Illicit drugs
The participant can attend the ritual as long as he has not consumed illicit drugs in the 24
hours preceding the ritual.

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Are you affected by any of the above cases? ( ) Yes ( ) No
If yes which ? ……………………. …………………………………………………………………

1 - Are you currently under medical treatment? ( ) Yes ( ) No

If yes which ?…………………….…………………………………………………………………

2 - Are you currently taking any medication? ( ) Yes ( ) No

If yes which ?…………………….…………………………………………………………………

3 - Has a doctor ever told you that you have a heart problem? ( )Yes ( ) No

If yes which ?…………………….…………………………………………………………………

4 - Do you know your blood pressure? ( ) Yes ( ) No

If yes what is it? ……………………. ……………………………. …………………………

5 - Which of these classifications suits you the most:

( ) Non hypertensive

( ) Controlled hypertension

( ) Uncontrolled hypertension

6 - Do you have diabetes? ( ) Yes ( ) No

If yes :

( ) Mastered

( ) Uncontrolled

( ) Insulin dependent

( ) Non-insulin dependent

7 - Do you have an allergy to certain types of medication? ( ) Yes ( ) No

If yes, which drugs: ……………………. …………………………………………………

8 - Do you have a stomach problem? ( ) Yes ( ) No

If yes which ?…………………….…………………………………………………………………

9 - Do you have another type of systemic problem that you wish to report?

( ) Yes ( ) No

If yes which ?…………………….…………………………………………………………………

10 - What is your blood type?

( ) O ( ) A ( ) AB ( ) B

( ) Positive ( ) negative

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 DECLARATION

" I declare :

a) be aware of all information provided and comply with the rules established for
participation in spiritual work;

b) have provided reliable information and do not need special medical care;

c) be aware of the particularly physical and health effects provided by the use of Nixipae
as an entheogenic element;

d) be aware of the rules of conduct during and after spiritual work ”.

I agree to stay in the room where the spiritual work is carried out until the end of it and not
to be absent in any case. "

Made in : …………………………………

Date: ………………………………….

Signature:

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