Microsoft word - atue form colour.doc

Please PRINT clearly using BLOCK CAPITALS First Name: ________________________________ Date of Birth (dd/mm/yy): _____________________ Address: _______________________________________________________________________________ _________________________________________________ Email: ________________________________ Home Tel: ____________________ Work Tel: ______________________ Mobile: _____________________ Discipline/Position: _______________________________ National Governing Body: __________________________ If athlete with a disability, please indicate disability: ______________________________________________ 2. Medical Information (attach any additional information on a separate sheet if necessary) Condition / injury sustained: ________________________________________________________________ (N.B. If Asthma, please state if Asthma is Exercise Induced / Intermittent / Persistent, etc.) Details of Diagnosis: ______________________________________________________________________ (N.B. If Asthma, please state what tests have been carried out, e.g. Auscultatory Evidence of Wheeze / Peak Flow Test / Laboratory Exercise Challenge Test, etc.) ◄ ATTENTION DOCTORS, PLEASE REFER TO MIMS TO CHECK IF ► Additional Information: _____________________________________________________________________ _______________________________________________________________________________________ 3. Physician’s Information and Declaration qualifications & medical specialty: _____________________________________________________ (e.g. Dr AB Cook, MD FRACP, Gastroenterologist) Address: _______________________________________________________________________________ ________________________________________________ Email: _________________________________ Work Tel: ____________________ Mobile: ________________________ Fax: _______________________ I certify that I am the athlete’s prescribing doctor. I further certify that the above-mentioned substance(s) for the above named athlete has been / are to be administered as the correct treatment for the above named medical condition. I further certify that the use of alternative medications not on the Prohibited List would be unsatisfactory for the treatment of the above named medical condition. Specify reason: __________________________________________________________________________ Physician’s signature: ________________________________________ Date: _____/_____/_______ I certify that the information under section 1 is accurate and that I am requesting approval to use a Substance or Method from the WADA Prohibited List. I authorise the release of personal medical information to the Irish Sports Council (ISC), the ISC Therapeutic Use Exemption Committee, the World Anti-Doping Agency (WADA), the WADA Therapeutic Use Exemption Committee and also to other Anti-Doping Organisations under the provisions of the Code. I understand that if I ever wish to revoke the right of any of the above listed organisations to obtain my health information on my behalf, I must notify my medical practitioner and the ISC Athlete’s signature: __________________________________________ Parent’s / Guardian’s signature: ________________________________ (if the athlete is a minor or has a disability preventing him/her to sign this form, a parent/guardian shall sign together with or on behalf of the athlete) reviated TUE forms are valid under the Irish Anti-Doping Programme for the duration of t he treatment as prescribed by the physician, up to a MAXIMUM OF TWO YEARS. IT IS THE ATHLETE’S RESPONSIBILITY TO REAPPLY SHOULD THEIR TUE EXPIRE. INCOMPLETE APPLICATIONS WILL BE RETURNED AND WILL NEED TO BE RESUBMITTED! E-mail: [email protected] If you require written approval, please send a stamped addressed envelope (S.A.E.) with your application. The section below will be completed & returned to you by post The Irish Sports Council will only approve this application for Therapeutic Use Exemption for the duration stated by the physician in section 2 of this form, up to a maximum of two years. If the duration of the prescribed treatment stated on this form exceeds two years from ___/___/___, the athlete must re-apply for Therapeutic Use Exemption prior to the expiry date. Signed ________________________________ (Anti-Doping Unit)


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