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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: 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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2012 Prescription Drug List Reference Guide Type of Drug ABORTIFACIENTS Drug Name Brand or Generic Type of Drug ACE INHIBITORS Drug Name Brand or Generic Type of Drug ADJUNCTIVE AGENTS Drug Name Brand or Generic Type of Drug ADRENAL HORMONES Drug Name Brand or Generic Type of Drug ADRENERGIC ANTAGONISTS & RELATED DRUGS Drug Name Brand o

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