Physician’s Statement

Obtaining a Physician’s Statement is a PATH (Professional Association of Therapeutic Horsemanship) requirement for safety. All participants MUST have this completed by a medical professional prior to participating in equine assisted activities. Please fill out the form to assist us in acquiring this statement.

Parent/ Guardian Name

First Name

Last Name

Participant/ Child Name

First Name

Last Name

Doctor's Office / Name of Provider

Address of Provider

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Provider

(###)

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Fax Number of Provider

(###)

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Form Preference

I will send the Physician's Statement to my child's provider and then deliver to Justin's Place.

Please send the form to my child's Provider. I understand I am responsible to make sure it gets to Justin's Place.