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INHALER REGISTRATION FORM
PART A
Application for Permission to use Beta 2 Agonist Inhalers
ATHLETE'S NAME
ADDRESS
EVENT(s) DATE OF BIRTH
PRESCRIBING DOCTOR'S NAME
DOCTOR'S ADDRESS
I wish to apply for exemption from the rules banning the use of certain inhalers.
SIGNATURE DATE
TYPE OF INHALER
DOSE
DIAGNOSIS
EXPECTED DURATION OF TREATMENT .
Please see other side
Data Protection
UK Athletics will process the data provided by you in this form for the sole purpose of the proper administration of its anti-doping programme. UK Athletics will process the data in accordance with the Data Protection Act (1998) and in so doing UK Athletics may pass your information (including information relating to personal medical information) to the IAAF, WAD A, UK Sport and other organisations or individuals involved in the administration of the doping control process or concerned with the results of that process.
INHALER REGISTRATION FORM
PART B
Application for Permission to use Beta 2 Agonist Inhalers
ATHLETE'S NAME
ADDRESS
TYPE OF INHALER
Please return this form to:
Dr Malcolm Brown
UK Athletics
Athletics House
Central Boulevard
Blythe Valley Business Park
Solihull
West Midlands B90 8AJ
Please enclose a stamped addressed envelope.
FOR OFFICIAL USE ONLY
I hereby grant the above athlete permission to use___________________________________
..by inhaler from ..
until
SIGNED ...
DATE ..