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Medical Exemption Request Form

National Horseshoe Pitchers Association

The Official Rules of Horseshoe Pitching states that “All Open Men and Senior contestants shall observe the 37-foot foul lines. Physically impaired males in these categories may be given permission by the governing NHPA officials to move onto the extended platforms and observe the 27 foot foul lines.” (See Rule 3, Section A, number 2) The NHPA has further delegated the responsibility of this decision-making to the various State Associations for acceptance or denial. The steps of this process are outlined below. Please complete Parts I and IV of this form and return it to:

Current EPHPA Secretary

Part I – Background Information

I, _________________________________, am applying for a medical exemption which would allow me to pitch horseshoes in NHPA sanctioned events from a distance of 30 feet, instead of 40 feet, due to the following medical condition and other information described below which I proclaim to be true and accurate.

· What is the name of this medical condition? _______________________________________________________________

· For how long have you had this condition? ______________________________________

· Do you consider this condition to be permanent or temporary? ____(permanent) ____(temporary)

· For how long have you pitched horseshoes? _____________________________________

· What is your current age? _______________________

· Explain what area(s) of your body are affected and why this condition prevents you from being able to pitch from 40 feet.

(Add an additional page if necessary) __________________________________________________________________________________________________________________________________________________________________________________________________________

· Have you seen a specialist about this medical condition? _____________________

· If so, for how long have you been under his/her care? _____________________

· Have you undergone surgery or other medical procedures for this condition? ____________________________________

· If this medical exemption is denied, will you continue pitching from 40 feet? _____________________________________

· The medical doctor more familiar with my medical condition is:

Name: ______________________________________ Telephone # ____________________________________________

Address: ___________________________________________________________________________________________

Part II – Charter Executive Council Review

Copies of the above information will be circulated among the Charter Council members for review. At this point, two-thirds or more of the council members must agree that this request deserves further consideration.

Part III – Medical Information and Professional Opinion

A separate medical questionnaire form may be sent to the attending physician for confirmation of the medical condition and for a professional opinion as it applies to the requested exemption.

Part IV – Consent for Release of Medical Information

I hereby give permission for my medical doctor to release to the EPHPA Charter Council any medical information about my health condition as it may relate to this exemption request.

Signature of Applicant_________________________________________________

Address__________________________________________________________________________________

Phone # __________________________________________ Date of Birth _______________________

NHPA card Number ___________________________________________________

Part V – Decision and Follow-up

Upon receiving the completed medical form from the attending physician, the State Secretary will re-circulate the combined forms among the Charter Council members for a final decision. Again, a two-thirds or greater vote will be required for acceptance of the medical exemption. The President of the Charter Council will notify the pitcher, in writing, of the Council’s decision and the pitcher may then, and only then, begin pitching in NHPA sanctioned events from the shorter distance. The State Charter shall periodically review the exemption and in cases where the doctor did initially not declare the condition permanent, an up-dated professional opinion statement may be requested. The NHPA Executive Council reserves the right to review, modify and/or withdraw this form at any time.

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Medical Information and Professional Opinion

National Horseshoe Pitchers Association

Dear Dr. ____________________________________

As you may know, horseshoe pitching is a nationally organized sporting event with an official set of rules. _________________________________________, a patient of yours, has requested a medical exemption from Rule 3, Section A, number 2. (See top of other form) and has given permission (see Part IV of other form) for you to complete this form and send your responses to the Eastern PA Horseshoe Pitchers Association. This exemption, if granted, would allow him to pitch from a shorter distance before reaching the age of 70; when men are officially given the option of pitching from this shorter distance. Your patient has completed Parts I and IV of the other enclosed form. Please look over this information and then respond to the questions below. We need this information and your professional opinion before we can act upon his request. Please return this completed form in the enclosed self-addressed, stamped envelope. Thank you for your assistance.

· What is the name of this medical condition? _______________________________________________________

· What area(s) of the body are affected? ___________________________________________________________

· For how long has this condition existed? __________________________________________________________

· For how long have you treated the patient for this condition? _________________________________________

· Do you consider this condition to be permanent? _______________ Temporary?________________________

o A temporary condition (ex: post-surgery) must be re-certified by a doctor every 3 years.

· Have other treatments been recommended by you? _________________________________________________

· Has this patient discussed with you the possibility of a medical exemption which would allow him to pitch horseshoes from a shorter distance? _____________________________________________________________

· Will you recommend that this patient NOT pitch horseshoes from a distance of 40 feet if the request for this exemption is denied? _________________________________________________________________________

Here is some additional information that may be helpful to your better understanding of how the physical requirements of horseshoe pitching could be affected by this exemption:

· The amount of walking may remain about the same, but could be greater since 30-foot pitchers may be required to return to the area of the stake while their opponent pitches.

· The amount of bending, stooping, etc. required for the retrieval and measurement of shoes should remain the same.

· The amount of physical force required to pitch the horseshoe a shorter distance will be less.

· Note: A horseshoe weighs about 2 ½ pounds and is pitched underhanded, as in softball.

In your professional opinion, will pitching a 2 ½ pound horseshoe from a distance of 40 feet more seriously aggravate this pitcher’s medical condition than pitching from a distance of 30 feet? _________________________

Other comments: _______________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of Physician ______________________________________ Date ________________________________

Name of Physician (printed) _______________________________ Physician telephone # __________________