PCA Horse Therapeutic Use Exemption application

PONY CLUB AUSTRALIA

Therapeutic Use Exemption (Horse medication declaration)
HOW TO USE THIS FORM

Certain medications may not be permitted in Pony Club activities. For details of the medications that are of concern, please refer to the FEI list.

http://prohibitedsubstancesdatabase.feicleansport.org/

A Pony Club member (individual) is required to inform the event organiser of the treatment record of their horse or pony used in Pony Club® competitions, and seek approval to compete.

A horse may be sampled at a competition and failure to declare the medication record for substances on the FEI list may result in a breach of the PCA Horse Medication Policy.

WHO CAN USE THIS FORM
- The rider or parent or guardian of the rider if the rider is under 18 years
This Form must be completed in full at the time of submission.

RIDER DETAILS
Name of rider*

First NameLast Name
Pony Club Member Number*
Age of Rider*

Over 18yrsUnder 18yrs
Name of person lodging this declaration (If rider is under 18 years)*
Rider or parent's phone*
Rider or parent's email*
Club you are a member of*
Club email address*
State your club is in*

HORSE/PONY DETAILS
Horse/pony name*
Horse/pony age*
What illness, disease, ailment or injury is affecting the horse or pony?*
Name and location of your veterinarian/veterinary surgeon*
Medication (name)*
Route of administration (injection, oral, inhalation, topical) *
Last treatment date*
Please upload the veterinary certificate here. The certificate should state the purpose of the treatment, that the medication does not have a performance-enhancing effect, and that it is not masking lameness or injury.

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EVENT DETAILS
Name of Event
Date of event
Event entry email address
Should be Empty: