MEDICAL EXEMPTION REQUEST FORM
NATIONAL HORSE SHOE 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:
Maine State Secretary
611 Ossipee Trail
Porter, Maine 04068
P A R T I - B A C K G R O U N D I N F O R M A T I O N
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?_________
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 medical exemption is denied, will you continue pitching from 40 feet?___________________________________
The medical doctor most familiar with my medical condition is:
(In order to speed the process you may provide your doctor with the Medical information and Professional opinion form located below to be sent directly to the State Secretary)
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 Maine Charter Council any medical information about my health condition as it may relate to this exemption request.
Signature of applicant_____________________________________________
Date of Birth_________________
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.
MEDICAL INFORMATION AND PROFESSIONAL OPINION
NATIONAL HORSESHOE PITCHERS ASSOCIATION
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 FV of
other form) for you to complete this form and send your responses to
The Maine Council. 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, addressed/stamped envelope. Thank you for your help.
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?______________________________________________
- 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
The amount of physical force required to pitch the horseshoe a shorter distance will be less.
- Note: A horseshoe weighs about 2 pounds and is pitched underhanded, as in softball.
In your professional opinion, will pitching a 2 pound horseshoe from a distance of 40 feet more seriously
aggravate this pitcher's medical condition than pitching from a distance of 30 feet?_________________________
Signature of Physician ____________________________________________Date____________________