PHYSICIAN REFERRAL
Pioneer Valley Therapeutic Riding Association (PVTRA) provides horseback riding lessons for children and adults with disabilities. Instructors, licensed by the Commonwealth of Massachusetts and certified through North American Riding for the Handicapped Association (NARHA) are on site. PVTRA is a NARHA Premiere Accredited Center and follows its instructional and safety guidelines. Realizing that riding is a controlled risk activity, we use safety equipment, specially screened and trained horses and trained volunteers.
Student’s Name: _________________________________ Date of Birth: _____________
Address: ________________________________________________________________
Name of Parent/Guardian: __________________________________________________
Height: _________________________________________ Weight: _________________ Diagnosis*:______________________________________________________________ ________________________________________________________________________
Date of Onset: ___________________________________________________________
Brief Medical History: ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Surgical Procedures: ______________________________________________________ ________________________________________________________________________
Medications: ____________________________________________________________
Side effects of medication(s): _______________________________________________
OVER
Please comment where applicable:
Hearing Neuro-sensation Muscle Tone
Vision Coordination Circulation
Speech Balance Seizures
Assistive Devices Allergies Incontinence
*For those with Down Syndrome: AtlantoDens Interval X-rays, Date: ________________
Result: _______________________________________________________________
Precautions or Contraindications to Riding: ____________________________________ ________________________________________________________________________
To my knowledge, there is no reason why this person cannot participate in supervised equine activities. However, I understand that PVTRA will weigh the medical information above against the existing NARHA guidelines for precautions and contraindications. Physician’s Name (please print): _________________________________Date: _______
Physician’s Signature: _____________________________________________________
Address: ________________________________________________ Phone: _________
