Dear Health Care Provider,

is in need of authorization to begin or continue participating in equine activities at Kids & Horses. Please review their previous medical history and provide medical information in the space below. Address occurrences including surgeries, illnesses, hospitalization and changes in medications, treatments, weight or behavior. Please indicate height and weight. For your reference, a list of potential precautions/contraindications is attached.

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For those with Down Syndrome:

An Atlantoaxial x-ray and annual exam to exclude Atlantoaxial instability for clients with Down Syndrome over the age of 3.

Given the above diagnosis and medical information, this person is not medically precluded from participation in supervised equestrian activities. I understand that Kids & Horses will weigh the medical information indicated above against any existing precautions and/or contraindications before allowing this person to participate in adaptive riding or physical therapy, occupational therapy or speech-language pathology utilizing equine movement as a treatment strategy. Therefore, I refer this person to Kids & Horses for ongoing evaluation to determine eligibility for participation.

Signature: *


Please note that the following conditions may suggest precautions and contraindications to horseback riding. Therefore, when completing this form, please note whether these conditions are present and to what degree.


Orthopedic *
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Neurologic: *
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Medical/Psychological *
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Other: *
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