Application Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
How did you hear about The Ripple Foundation? POLICIES: CONFIDENTIALLY: It is of the utmost importance that we hold confidential any and all personal information that may be shared during the Journey. It is our commitment and intention to create an environment in which everyone feels safe. We may become aware of ourselves on a deeper and sometimes more vulnerable level. Anything that is shared stays confidential. COMITTMENT: This is an interactive experience; full attendance and participation is expected. Some of the Journey’s will contain recommended reading and homework. PERSONAL HEALTH: It is important that regular attention be given to the care of our physical, mental, emotional and spiritual health. It is recommended that no alcohol be consumed the day prior, or the day of a Journey. By signing this I agree to the above policies –
Date
Signature Print Name
www.TheRippleFoundation.com Welcome Letter – page 1 of 1
Please answer briefly the following questions: 1) What is your experience with self-development, alternative medicine and/or healing?
2) What books have you read or other classes have you taken on self-transformation?
3) How is it that you currently spend your time?
4) What desire do you have that you have yet to manifest in your life? What do you believe is preventing this desire from manifesting?
5) Please describe your current state of health. What events of your health history have most impacted your health and why?
6) What would you like to get out of this class?
7) What is it that you feel that you have to offer this class?
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 2 of 2
Health Intake and Medical History Form Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
Special needs– List any which the staff should be aware of (medical, emotional, learning)
Allergies- Include medication, food and others (insect stings, hay fever, asthma, animal dander, etc.) List all known. Describe reaction and management of the reaction.
Dietary Restrictions: Kosher __ Vegetarian__ Does not eat: Meat __ Pork __ Peanuts __ Dairy products __ Wheat __ Eggs __ Other Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary)
www.TheRippleFoundation.com Welcome Letter – page 3 of 1
MEDICAL HISTORY (please note significant disorders): Recent injury, illness or infectious disease Chronic or recurring illness/condition Hospitalizations Surgery Headaches Head injury Seizures Chest pain during or after exercise High blood pressure Diabetes Ever been dizzy during or after exercise Asthma Depression Anxiety Other Pertinent medical history
Yes ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medications Please list ALL medications (including over-the counter or nonprescription drugs) taken routinely. Bring enough medication to last the course. Keep medication in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. Med # 1 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________ Med # 2 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 4 of 2
Acknowledgement and Assumption of Risks and Liability Release and Indemnity Agreement
In consideration of the services of The Ripple Foundation, participant acknowledges and agrees as follows: Acknowledgement and Assumption of Risk I understand that participant shares the responsibility for participant’s safety, for managing the risks, and for determining the participant’s suitability for the program in which she/he will participate. I have accurately completed any required application and medical forms and have reviewed all of The Ripple Foundation program information provided to me. I agree to obey all rules, regulations and policies of The Ripple Foundation. I have no mental or physical problems or limitations that might affect my ability to participate that have not been disclosed to The Ripple Foundation in writing. I have had the opportunity to ask questions about the program activities and the risks of the program in which I will participate. I understand and acknowledge that the programs in which I will participate has risks and may be physically, mentally or emotionally strenuous. It is impossible to anticipate every activity in which I will engage. The Ripple Foundation offers numerous courses with a variety of activities. The list below may include many of those activities. The activities in my course will depend on the program in which I am enrolled and may include hiking, backpacking, ropes and or challenge courses, water crossings, physical problem solving activities, individual time alone in a wilderness setting and vehicle travel. Activities may be supervised or unsupervised. I understand that I may engage in other activities not listed above. The program plan may be modified for any number of reasons, including convenience, weather, emergencies, or unexpected conditions. It is impossible to know or list every risk associated with every activity. Risks will depend on the program. Some, but not all, of the risks I may encounter include: unpredictable or harsh weather, earthquakes, lightening, wild animals, disease carrying or poisonous plants, insects, and animals, improper or malfunctioning equipment, slipping, falling, or being struck by object or persons; risks caused or complicated by any mental, physical, or emotional conditions any participant may have; being separated from other participants and leaders for considerable periods; physical contact with other participants or other individuals; and other natural or manmade hazards. I acknowledge that participating in The Ripple Foundation program involves inherent risks and other risks, hazards, and dangers including some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma or disability.
www.TheRippleFoundation.com Welcome Letter – page 5 of 1
Liability Release and Indemnity Agreement I hereby forever release, waive, and discharge The Ripple Foundation and each of its respective agents, employees, officers, directors, trustees, independent contractors, volunteers, and all other persons or entities acting under their direction and control (collectively referred to as the “Released Parties”) from, and agree not to pursue a claim or sue the Release Parties or any of them for any liability, claim, or expense in any way associated with my participation in The Ripple Foundation program or the use of any equipment or facilities. Neither I nor anyone acting on my behalf will make a claim against the Released Parties as a result of any injury, illness, damage, death, or loss. This release includes any losses caused, in whole or in part, by negligence, whether active or passive, of the Released Parties to the fullest extent allowed by law (but not for gross negligence) and includes claims for property damage, wrongful death, breach of contract, or any type of suit. I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT. I UNDERSTAND THAT I AM SURRENDERING CERTAIN LEGAL RIGHTS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, OTHER FAMILY MEMBERS AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE. I AGREE ON MY OWN TO THE TERMS AND CONDITIONS OF THIS DOCUMENT
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 6 of 2
Application Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
How did you hear about The Ripple Foundation? POLICIES: CONFIDENTIALLY: It is of the utmost importance that we hold confidential any and all personal information that may be shared during the Journey. It is our commitment and intention to create an environment in which everyone feels safe. We may become aware of ourselves on a deeper and sometimes more vulnerable level. Anything that is shared stays confidential. COMITTMENT: This is an interactive experience; full attendance and participation is expected. Some of the Journey’s will contain recommended reading and homework. PERSONAL HEALTH: It is important that regular attention be given to the care of our physical, mental, emotional and spiritual health. It is recommended that no alcohol be consumed the day prior, or the day of a Journey. By signing this I agree to the above policies –
Date
Signature Print Name
www.TheRippleFoundation.com Welcome Letter – page 1 of 1
Please answer briefly the following questions: 1) What is your experience with self-development, alternative medicine and/or healing?
2) What books have you read or other classes have you taken on self-transformation?
3) How is it that you currently spend your time?
4) What desire do you have that you have yet to manifest in your life? What do you believe is preventing this desire from manifesting?
5) Please describe your current state of health. What events of your health history have most impacted your health and why?
6) What would you like to get out of this class?
7) What is it that you feel that you have to offer this class?
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 2 of 2
Health Intake and Medical History Form Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
Special needs– List any which the staff should be aware of (medical, emotional, learning)
Allergies- Include medication, food and others (insect stings, hay fever, asthma, animal dander, etc.) List all known. Describe reaction and management of the reaction.
Dietary Restrictions: Kosher __ Vegetarian__ Does not eat: Meat __ Pork __ Peanuts __ Dairy products __ Wheat __ Eggs __ Other Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary)
www.TheRippleFoundation.com Welcome Letter – page 3 of 1
MEDICAL HISTORY (please note significant disorders): Recent injury, illness or infectious disease Chronic or recurring illness/condition Hospitalizations Surgery Headaches Head injury Seizures Chest pain during or after exercise High blood pressure Diabetes Ever been dizzy during or after exercise Asthma Depression Anxiety Other Pertinent medical history
Yes ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medications Please list ALL medications (including over-the counter or nonprescription drugs) taken routinely. Bring enough medication to last the course. Keep medication in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. Med # 1 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________ Med # 2 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 4 of 2
Acknowledgement and Assumption of Risks and Liability Release and Indemnity Agreement
In consideration of the services of The Ripple Foundation, participant acknowledges and agrees as follows: Acknowledgement and Assumption of Risk I understand that participant shares the responsibility for participant’s safety, for managing the risks, and for determining the participant’s suitability for the program in which she/he will participate. I have accurately completed any required application and medical forms and have reviewed all of The Ripple Foundation program information provided to me. I agree to obey all rules, regulations and policies of The Ripple Foundation. I have no mental or physical problems or limitations that might affect my ability to participate that have not been disclosed to The Ripple Foundation in writing. I have had the opportunity to ask questions about the program activities and the risks of the program in which I will participate. I understand and acknowledge that the programs in which I will participate has risks and may be physically, mentally or emotionally strenuous. It is impossible to anticipate every activity in which I will engage. The Ripple Foundation offers numerous courses with a variety of activities. The list below may include many of those activities. The activities in my course will depend on the program in which I am enrolled and may include hiking, backpacking, ropes and or challenge courses, water crossings, physical problem solving activities, individual time alone in a wilderness setting and vehicle travel. Activities may be supervised or unsupervised. I understand that I may engage in other activities not listed above. The program plan may be modified for any number of reasons, including convenience, weather, emergencies, or unexpected conditions. It is impossible to know or list every risk associated with every activity. Risks will depend on the program. Some, but not all, of the risks I may encounter include: unpredictable or harsh weather, earthquakes, lightening, wild animals, disease carrying or poisonous plants, insects, and animals, improper or malfunctioning equipment, slipping, falling, or being struck by object or persons; risks caused or complicated by any mental, physical, or emotional conditions any participant may have; being separated from other participants and leaders for considerable periods; physical contact with other participants or other individuals; and other natural or manmade hazards. I acknowledge that participating in The Ripple Foundation program involves inherent risks and other risks, hazards, and dangers including some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma or disability.
www.TheRippleFoundation.com Welcome Letter – page 5 of 1
Liability Release and Indemnity Agreement I hereby forever release, waive, and discharge The Ripple Foundation and each of its respective agents, employees, officers, directors, trustees, independent contractors, volunteers, and all other persons or entities acting under their direction and control (collectively referred to as the “Released Parties”) from, and agree not to pursue a claim or sue the Release Parties or any of them for any liability, claim, or expense in any way associated with my participation in The Ripple Foundation program or the use of any equipment or facilities. Neither I nor anyone acting on my behalf will make a claim against the Released Parties as a result of any injury, illness, damage, death, or loss. This release includes any losses caused, in whole or in part, by negligence, whether active or passive, of the Released Parties to the fullest extent allowed by law (but not for gross negligence) and includes claims for property damage, wrongful death, breach of contract, or any type of suit. I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT. I UNDERSTAND THAT I AM SURRENDERING CERTAIN LEGAL RIGHTS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, OTHER FAMILY MEMBERS AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE. I AGREE ON MY OWN TO THE TERMS AND CONDITIONS OF THIS DOCUMENT
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 6 of 2
Application Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
How did you hear about The Ripple Foundation? POLICIES: CONFIDENTIALLY: It is of the utmost importance that we hold confidential any and all personal information that may be shared during the Journey. It is our commitment and intention to create an environment in which everyone feels safe. We may become aware of ourselves on a deeper and sometimes more vulnerable level. Anything that is shared stays confidential. COMITTMENT: This is an interactive experience; full attendance and participation is expected. Some of the Journey’s will contain recommended reading and homework. PERSONAL HEALTH: It is important that regular attention be given to the care of our physical, mental, emotional and spiritual health. It is recommended that no alcohol be consumed the day prior, or the day of a Journey. By signing this I agree to the above policies –
Date
Signature Print Name
www.TheRippleFoundation.com Welcome Letter – page 1 of 1
Please answer briefly the following questions: 1) What is your experience with self-development, alternative medicine and/or healing?
2) What books have you read or other classes have you taken on self-transformation?
3) How is it that you currently spend your time?
4) What desire do you have that you have yet to manifest in your life? What do you believe is preventing this desire from manifesting?
5) Please describe your current state of health. What events of your health history have most impacted your health and why?
6) What would you like to get out of this class?
7) What is it that you feel that you have to offer this class?
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 2 of 2
Health Intake and Medical History Form Today’s Date_________ Journey Name & Dates Name Address Phone: Home (___) _________________Cell (___)_________________ E-mail_____________________________________________________ Date of Birth___________ Age____ M F Emergency contact Phone (___)_______________
Relationship
Special needs– List any which the staff should be aware of (medical, emotional, learning)
Allergies- Include medication, food and others (insect stings, hay fever, asthma, animal dander, etc.) List all known. Describe reaction and management of the reaction.
Dietary Restrictions: Kosher __ Vegetarian__ Does not eat: Meat __ Pork __ Peanuts __ Dairy products __ Wheat __ Eggs __ Other Explain any restrictions to activity (e.g., what cannot be done, what adaptations or limitations are necessary)
www.TheRippleFoundation.com Welcome Letter – page 3 of 1
MEDICAL HISTORY (please note significant disorders): Recent injury, illness or infectious disease Chronic or recurring illness/condition Hospitalizations Surgery Headaches Head injury Seizures Chest pain during or after exercise High blood pressure Diabetes Ever been dizzy during or after exercise Asthma Depression Anxiety Other Pertinent medical history
Yes ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Medications Please list ALL medications (including over-the counter or nonprescription drugs) taken routinely. Bring enough medication to last the course. Keep medication in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. Med # 1 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________ Med # 2 ___________________ Dosage ___________ Specific times taken each day _______________________________ Reason for taking_________________________________________
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 4 of 2
Acknowledgement and Assumption of Risks and Liability Release and Indemnity Agreement
In consideration of the services of The Ripple Foundation, participant acknowledges and agrees as follows: Acknowledgement and Assumption of Risk I understand that participant shares the responsibility for participant’s safety, for managing the risks, and for determining the participant’s suitability for the program in which she/he will participate. I have accurately completed any required application and medical forms and have reviewed all of The Ripple Foundation program information provided to me. I agree to obey all rules, regulations and policies of The Ripple Foundation. I have no mental or physical problems or limitations that might affect my ability to participate that have not been disclosed to The Ripple Foundation in writing. I have had the opportunity to ask questions about the program activities and the risks of the program in which I will participate. I understand and acknowledge that the programs in which I will participate has risks and may be physically, mentally or emotionally strenuous. It is impossible to anticipate every activity in which I will engage. The Ripple Foundation offers numerous courses with a variety of activities. The list below may include many of those activities. The activities in my course will depend on the program in which I am enrolled and may include hiking, backpacking, ropes and or challenge courses, water crossings, physical problem solving activities, individual time alone in a wilderness setting and vehicle travel. Activities may be supervised or unsupervised. I understand that I may engage in other activities not listed above. The program plan may be modified for any number of reasons, including convenience, weather, emergencies, or unexpected conditions. It is impossible to know or list every risk associated with every activity. Risks will depend on the program. Some, but not all, of the risks I may encounter include: unpredictable or harsh weather, earthquakes, lightening, wild animals, disease carrying or poisonous plants, insects, and animals, improper or malfunctioning equipment, slipping, falling, or being struck by object or persons; risks caused or complicated by any mental, physical, or emotional conditions any participant may have; being separated from other participants and leaders for considerable periods; physical contact with other participants or other individuals; and other natural or manmade hazards. I acknowledge that participating in The Ripple Foundation program involves inherent risks and other risks, hazards, and dangers including some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma or disability.
www.TheRippleFoundation.com Welcome Letter – page 5 of 1
Liability Release and Indemnity Agreement I hereby forever release, waive, and discharge The Ripple Foundation and each of its respective agents, employees, officers, directors, trustees, independent contractors, volunteers, and all other persons or entities acting under their direction and control (collectively referred to as the “Released Parties”) from, and agree not to pursue a claim or sue the Release Parties or any of them for any liability, claim, or expense in any way associated with my participation in The Ripple Foundation program or the use of any equipment or facilities. Neither I nor anyone acting on my behalf will make a claim against the Released Parties as a result of any injury, illness, damage, death, or loss. This release includes any losses caused, in whole or in part, by negligence, whether active or passive, of the Released Parties to the fullest extent allowed by law (but not for gross negligence) and includes claims for property damage, wrongful death, breach of contract, or any type of suit. I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT. I UNDERSTAND THAT I AM SURRENDERING CERTAIN LEGAL RIGHTS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, OTHER FAMILY MEMBERS AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE. I AGREE ON MY OWN TO THE TERMS AND CONDITIONS OF THIS DOCUMENT
Date
Signature Print Name
www.TheRippleFoundation.com Participant Health Intake and Medical History Form – page 6 of 2