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Rippleffect.net

Please return completed forms to:
Rippleffect, Inc.
Health and Registration Form
Name of participant: ________________________________ Date of birth: ________________ Male______ Female _______
(If under 18) Parent/Guardian Name(s): _________________________________Relation to Participant: ______________
Address: Street____________________________________ City______________________ State_______ Zip ____________ Home Phone: ________________________Work Phone: ________________________Cel : ___________________________ Email: _______________________ Program Name and Dates of Registration: ______________________________________ General Health History Please be as thorough as possible!
Failure to report important medical information can result in injury or illness or may compound the severity of an injury or illness. PAST HISTORY
CONDITIONS
ALLERGIES
Are there any other medical conditions, physical limitations or recurrent injuries or illnesses that may restrict participation? If so, what are they? ______________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Please use space provided below or on the back to explain any treatment or explanation of any of the above: __________________ __________________________________________________________________________________________________________ Special Diet Needs or Restrictions: ______________________________________________________________________________
Medication:
□ This participant WILL NOT take any medications while attending this program □ This participant will take the following medications during the program: Please send all medications in original pharmacy containers with labels which show the participant’s name and how the medication should be given. Provide enough medication to last the duration of the program. Rippleffect staff will administer medications. Name of medication
Date started
Reason for taking it
When it is given
Amount or dose given How it is given
(specify time of day)
(Form continues on back)
Pa rticipant Name:______________________________________ Program Name:_____________________
Th e following non-prescription medications are used by Rippleffect on an as needed basis to manage illness and injury. Please
cross out any of these medications that the participant should NOT be given.

Acetaminophen (Tylenol)
ealth history is correct and accurately reflects the health status of the named participant. Signature of participant: ____________________________________________ Date: ________________ (For participants under 18 years of age) Signature of parent/legal guardian: ___________________________________ Date: _______________ Emergency Contact Information
Primary Emergency Contact
Name: ___________________________________Relationship: __________________
Daytime Phone: ________________Evening Phone: _________________Cell phone: __________________________

Secondary Emergency Contact Name: _________________________________Relationship: _________________
Daytime Phone: __________________Evening Phone: ________________Cell phone: _________________________
Primary Care Provider (PCP) Name, Phone Number and Address: ___________________________________________ ________________________________________________________________________________________________ participants under 18 who self-administer emergency medication:
I verify that _______________ (participant’s name) has the knowledge and skills to safely self-administer the following emergency medication as necessary:_____________________________. I give permission for him/her to self-administer this medication whenever necessary during the Rippleffect program. Signature of Primary Care Provider:____________________________ Printed Name:________________________ Signature of parent/legal guardian:________________________________________ Date:___________________

Source: http://www.rippleffect.net/wp-content/uploads/2012/02/Health-Form-2014.pdf

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Specialty Pharmacy Continuum • Spring 2012 EDUCATIONAL REVIEW All rights r Copyright © 2011 McMahon Publishing Gr eserved. Repr ors is an care and must be a core mission of every pharmacy. For medication error prevention efforts oduction in whole or in part without permission is pr to be effective, they must become a priority. The first step in setting up an error-re

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