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Glossopasc.co.uk

MEDICATION DECLARATION FORM
I am an athlete and completing this form because I am: Representing Great Britain or my Home Country internationally Competing in a British Swimming, ASA, SASA or WASA National event (all disciplines, excluding masters)
A new form MUST be completed annually even if the medication prescribed has not been altered or if no
medication is being taken and whenever the medication is changed. If the competitor is under the age of 18 this
form should be completed and returned by the parent or person in loco parentis but must still be signed by the
competitor.
This form should be sent direct to British Swimming, not via the club registration/welfare officer. The data
contained in this form is classed as sensitive personal data under the Data Protection Act 1998 (DPA). The ASA,
SASA, WASA or BS will process the data provided in accordance with the DPA. Your express written consent to
hold this data is required under the DPA, which by signing this form you are providing. The data will be held
securely in accordance with the DPA and will be used to administer you as a member of the ASA, SASA or
WASA.
Please complete and return a signed copy before your departure to:
Rachel Burrows – Anti-Doping Manager
British Swimming,
Sportpark,
3 Oakwood Drive,
Loughborough University,
Leicestershire, LE11 3QF

Miss / Mr / Ms / Mrs
First Name
Post Code:
Membership Number:
Club Name:
World Class Squad: (please tick where applicable)

Disability Swimming

Swimming
Podium Potential
Water Polo
Signature of athlete:
If under 18 years of age signature of parent or person in loco parentis:
Please list below ALL medication currently being taken on a regular basis for any other medical condition including vitamins and dietary or nutritional supplements in the space below or tick the ‘no medication’ box below: MEDICINES
Name of medication
Dosage and frequency per day
VITAMINS/ OTHER SUPPLEMENTS
Brand name and main ingredient (if listed)
Dosage and frequency per day
Medication
Ingredient status – as of July 2013
Salbutamol inhalation is not prohibited up to a maximum of 1600 micrograms over 24 hours. This threshold is not valid in the presence of diuretics. If you are using a diuretic you must have a Therapeutic Use Exemption to use both the diuretic and salbutamol. Injections and oral prohibited. Salmeterol is not prohibited when taken by inhalation in accordance with the manufacturers’ recommended therapeutic regime (inhalation) Formoterol inhalation is not prohibited up to a maximum of 54 micrograms over 24 hours. This threshold is not valid in the presence of diuretics. If you are using a diuretic you must have a Therapeutic Use Exemption to use both the diuretic and formoterol. Injections and oral prohibited. Out of competition - not prohibited. In competition = prohibited oral or rectal Out of competition - not prohibited. In competition = prohibited oral, rectal or intra- Where prohibited is listed, an application for a TUE must be applied for I declare that I do not take any form of medication
(this includes vitamins and supplements) - please tick box

Source: http://glossopasc.co.uk/BS_Med_dec_form_-_July_2013_v5_1.pdf

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Able Trek TOURS P.O. Box 384, Reedsburg, WI 53959 Able Trek 1-800-205-6713 FAX - (608)524-8302 MEDICAL EVALUATION Must be completed by a Medical Physician TRAVELER’S NAME: __________________________________ Date of exam: _______________ Address: ____________________________________________ City: _______________________ State: ______ Zip: _______ Phone: (_____

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