Medical Permission Form printable pdf download

Medical Permission Form

GRANDPA JACK: INTEGRATED EXPERIENTIAL THERAPY CENTER

Medical Permission form

For Participation in Horseback-riding Therapeutic Horseback-riding Lessons

Name: __________________________

Birthday: ________________________

Age: ____________________________

Sex: ____________________________

Medical status:

_____________________________________________________________________

Medical diagnosis: _____________________________________________________

Down syndrome: Yes No

Tetanus vaccine: Yes No, Date: ______________________

Please indicate if the applicant suffered or suffers today from any of the following

illnesses:

Hearing disorder

Yes

Epilepsy

Indicate type:

Sight disorder

Scoliosis

Indicate type:

Allergies

Emophilia

Heart disease

Surgery

In past year:

Blood pressure

Asthma

Balance

Neurological

disorders

Other: _______________________________________________________________

Medical Permission Form