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World Rugby Handbook

THERAPEUTIC USE EXEMPTION (TUE) APPLICATION FORM World Rugby fax: +353 1 2409 289 Schedule 3b e-mail:TUE@worldrugby.org SECTION F - Player's Declaration I,…………………………………………………….… certify that the information under Section A & B is accurate and that I am requesting approval to use a Prohibited Substance or Method from the WADA Prohibited List. I authorise the recording (whether electronically or otherwise) and/or storage by release of personal medical information to the Anti Doping Organisation, relevant Tournament Organisers as well as to WADA staff and to the WADA TUEC under the provisions of the Code. I understand that if I ever wish to revoke the right of the relevant TUEC or WADA TUEC to obtain my health information on my behalf, I must notify my medical practitioner in writing of that fact. I also understand that if I withdraw my consent to the release of my personal medical information, I may not receive approval for a TUE or the renewal of an existing TUE, since no TUE can be granted or renewed without the disclosure of comprehensive medical data. I am aware that an application for a TUE requires the processing (for example transmission, disclosure, use and storage) of all data pertaining to such application through relevant anti-doping administration/data management systems including but not limited to ADAMS* to ensure harmonized, coordinated and effective anti-doping programs for detection, deterrence and prevention of doping. Signing this form will indicate that I have been so informed and that I give my express consent to such processing of data. I understand and agree that my application for a TUE will only be considered following the submission in ADAMS or otherwise, by myself or by my Anti- Doping Organistion (ADO), of the present completed application form, as well as all relevant documents related to the application. I understand and agree that my TUE related data will be made accessible through ADAMS and/or any other relevant anti-doping administration/data management system, to the authorized ADO, to WADA and to the Therapeutic Use Exemption Committee. I understand and agree that if a TUE is granted, such TUE and the related information will be stored electronically in ADAMS (and/or in any other relevant anti-doping administration/data management system) for a minimum period of 10 years, the period of 10 years being the period within which an action can be commenced following a violation of an anti-doping rule contained in the WADA Code/World Rugby Regulation 21. WADA, ADOs and Therapeutic Use Exemption Committees will not disclose any of my TUE related information beyond those persons within their organisation with a need to know for doping control purposes according to the Code. I understand that if I believe that my personal information is not used in conformity with this consent and the International Standard for the Protection and Privacy and Personal Information I can file a compliant to WADA or CAS. RELEASE I hereby release WADA as well as ADOs and TUE Committees from all claims, demands, liabilities, damages, costs and expenses that I may have arising in connection with the processing of my TUE related data through ADAMS and/or any other relevant anti-doping administration/data management system. WITHDRAWAL OF CONSENT I understand that I may at any time revoke my consent for the processing of my TUE related data through ADAMS and/or any other relevant antidoping administration/data management system. I also understand that as a consequence of such withdrawal of consent, I will not receive approval for a TUE or a renewal of an existing TUE. Player's Signature: Date: / / Parent's/Guardian's Signature: Date: / / (if a Player is a minor a parent or guardian shall sign together with or on behalf of the Player) (Day/Month/Year) * ADAMS is the Anti-Doping Administration and Management System, which has been developed to enable athletes and anti-doping organisations to enter and share data related to doping control. ADAMS is an on-line, web-based system, which allows restricted sharing of data only with those organisations with the right to access such data in accordance with the World Anti-Doping Code. SECTION G – Application Notes Note 1 Diagnosis: Evidence confirming the diagnosis must be attached and forwarded with this application. The medical evidence should include a comprehensive medical history and the results of all relevant examinations, laboratory investigations and imaging studies (where applicable). Copies of the original reports or letters should be included where possible. Evidence should be as objective as possible in the clinical circumstances and in the case of non-demonstrable conditions independent supporting medical opinion will assist this application. World Rugby TUEC Contact Details World Rugby, World Rugby House, 8-10 Lower Pembroke Street, Dublin 2, Ireland Tel: +353 1 2409 212 Fax: +353 1 2409 289 Email: tue@worldrugby.org INCOMPLETE OR ILLEGIBLE APPLICATIONS WILL BE RETURNED AND WILL NEED TO BE RESUBMITTED. Last update: 14 January, 2015 456 STRICTLY CONFIDENTIAL


World Rugby Handbook
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