Я, (имя, фамилия), удостоверяю, что информация, изложенная в пунктах 1,5 и 6, верная. Я разрешаю свободное предоставление личной медицинской информации Международному союзу конькобежцев, а также полномочным представителям ВАДА, Комитету терапевтического использования ВАДА и другим антидопинговым комитетам и их представителям, которые имеют право на эту информацию под эгидой всемирного антидопингового кодекса и международного стандарта. Я согласен, чтобы мои врачи предоставили вышеуказанным лицам, информацию о моем здоровье, которую они посчитают необходимой в случае рассмотрения моего заявления. Я понимаю, что моя информация может быть использована только по запросу, Комитета терапевтического использования и в контексте расследования нарушений антидопинговых правил. Я понимаю, что если я когда либо захочу:
1) получить больше информации об использовании моих медицинских данных;
2) осуществить свои права в доступе и коррекции
3) аннулировать право этих организаций на получение информации о моих данных,
я должен уведомить моего врача и международный комитет конькобежцев об этом факте.
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7. Athlete’s declaration
I, certify that the information set out
... at sections 1, 5 and 6 is accurate. I authorize the release of personal medical information to the International Skating Union (ISU) as well as to WADA authorized staff, to the WADA TUEC (Therapeutic Use Exemption Committee) and to other ADO TU’ECs and authorized staff that may have a right to this information under the World Anti-Doping Code ("Code") and/or the International Standard for Therapeutic Use Exemptions.
I consent to my physician(s) releasing to the above persons any health information that they deem necessary in order to consider and determine my application.
I understand that my information will only be used for evaluating my TUE request and in the context of potential anti-doping rule violation investigations and procedures. I understand that if I ever wish to (1) obtain more information about the use of my health information; (2) exercise my right of access and correction; or (3) revoke the right of these organizations to obtain my health information, I must notify my medical practitioner and the ISU in writing of that fact. I understand and agree that it may be necessary for TUE-related information submitted prior to revoking my consent to be retained for the sole purpose of establishing a possible anti-doping rule violation, where this is required by the Code.
I consent to the decision on this application being made available to all ADOs, or other organizations, with Testing authority and/or results management authority over me.
I understand and accept that the recipients of my information and of the decision on this application may be located outside the country where I reside. In some of these countries data protection and privacy laws may not be equivalent to those in my country of residence.
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 of Privacy and Personal Information, I can file a complaint to WADA or CAS.
Athlete’s signature: Date:
Parent’s/Guardian’s signature: Date:
(if the athlete is a minor or has a disability preventing himu’her from signing this form. A parent or guardian shall sign together with or on behalf of the athlete)
Please submit the completed form to the ISU either by post or email at [email protected]
and keep a copy for your records/
I consent to my physician(s) releasing to the above persons any health information that they deem necessary in order to consider and determine my application.
I understand that my information will only be used for evaluating my TUE request and in the context of potential anti-doping rule violation investigations and procedures. I understand that if I ever wish to (1) obtain more information about the use of my health information; (2) exercise my right of access and correction; or (3) revoke the right of these organizations to obtain my health information, I must notify my medical practitioner and the ISU in writing of that fact. I understand and agree that it may be necessary for TUE-related information submitted prior to revoking my consent to be retained for the sole purpose of establishing a possible anti-doping rule violation, where this is required by the Code.
I consent to the decision on this application being made available to all ADOs, or other organizations, with Testing authority and/or results management authority over me.
I understand and accept that the recipients of my information and of the decision on this application may be located outside the country where I reside. In some of these countries data protection and privacy laws may not be equivalent to those in my country of residence.
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 of Privacy and Personal Information, I can file a complaint to WADA or CAS.
Athlete’s signature: Date:
Parent’s/Guardian’s signature: Date:
(if the athlete is a minor or has a disability preventing himu’her from signing this form. A parent or guardian shall sign together with or on behalf of the athlete)
Please submit the completed form to the ISU either by post or email at [email protected]
and keep a copy for your records/
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