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
Clinicals – Dispelling the Myths Index 1 NICE - Long-acting reversible contraception. Baxter N, Hudson H, Rogerson L, Duffy S. 2 Hysteroscopic sterilisation: a study of women’s attitudes to a novel procedure. Faculty of Family Planning and Reproductive Heath Care Guidance (April 2004). 3 The Levonorgestrel-releas
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: (_____
MEDICATION DECLARATION FORM 
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