Medical Clearance Form
Equestrian Team Members
Full Name
Date of Birth
Today's Date
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Relationship
Medical Information
Physician Name
Physician Phone Number
Current Medical Conditions
Allergies (including drug/food/other)
Current Medications
Previous Injuries (especially related to riding or sports)
Medical Clearance (to be completed by Physician)
Is the individual cleared to participate in equestrian activities?
Yes
No
With Restrictions
If restrictions, please specify
Additional Physician Notes
Physician Signature
Date