BUCS EUSA Registration

CONTACT DETAILS

Name (as per passport) *

Gender *

Email Address *

Contact Phone Number *

Address *

Postcode *

SPORT DETAILS

Sport *

I am a *

PASSPORT DETAILS

Passport Number *

Passport Expiry Date *

Passport issued by *

Nationality on passport *

Date of birth *

Place of Birth *

UNIVERSITY INFORMATION

University *

If you are a student, what is your course and level of study

If you are a student, when is your course end date?

ADDITIONAL INFORMATION

Next of Kin 1 *

Next of Kin 2 *

Do you have any dietary requirements? *

MEDICAL HISTORY

Personal Doctor's name and contact details. Please also include a Hospital Number, if under hospital care *

Please describe all serious old, chronic or existing injuries and previous operations. *

Please describe all serious, illness or chronic medical conditions *

Please list any allergies or sensitivies

What is your blood group

Please add any other important medication information that you feel is relevant

We need to know your current TUE (Theraputic Use Exemption).

The following details are requrired: substance, details, method of administration, date submitted, expiry date and granted by.

Please detail any current TUE (Therapeutic Use Exemption) here

TEAM MEMBER'S AGREEMENT

Please make sure that you have downloaded, read and understood the Team Member's Agreement .

TEAM MEMBER'S AGREEMENT *

I confirm that I have read and understood my entitlements and obligations and agree to abide by the terms of the Team Member’s Agreement

INFORMATION CONFIRMATION

By clicking submit your information will be processed and you will not be able to change any of these details

CONSENT *

I hereby confirm that the information above is accurate and complete. I confirm that I am not taking any banned substances and I will not take any medication or supplements during the games without first consulting a member of the medical team. All information contained herein is confidential and will only be available to the medical team. I also agree in the case of emergency that information can be obtained from my doctor at home.

EUSA Registration