I have examined the general physical condition of ________________________________ and
find the said participant to be physically fit to participate in the camp/ horseback riding lesson or game activities as indicated by the date of examination and by my signature. (Physical examination must be taken no more than one (1) year prior to participants’ attendance at camp/ conference.)




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Physician’s Signature


No participant shall be able to take part in the camp/ horseback riding lesson or game activities unless a licensed physician of medicine or osteopathic medicine, a certified School nurse practitioner, or a physician’s assistant has examined him/her.

Cedar Lane Stables

Physician’s Permission Form for all Participants

_____________________
Date of Examination