FEI ATHLETE LICENCE APPLICATION 2017

First Name Surname Date of Birth

Address:

Address

Mobile Phone (In the case of a minor please give Parent/ Guardian Mobile or other Contact Number)

GenderNationalityNationality

E-mail address(In the case of a minor please give Parent/ Guardian e-mail address)

Tick box if applicant

doesn’t havean e-mail account!

Discipline: (eg jumping, dressage) Pony: Junior: Young: Senior:

Annual or single licence Event if a single licence (SINGLE EVENT LICENCES CAN ONLY BE ISSUED FOR NAMED EVENTS IN IRELAND)

NOTE: In order to be granted an FEI Athlete Licence you must be registered with the recognized Affiliate for the discipline (section 2 of the Horse Sport Ireland General Rules) you wish to compete for the current year. Your application will not be processed otherwise. Please indicate the Affiliate with which you are registered for 2016.

SJ IRL Eventing IRL DRESSAGE IRL DRIVING ILDRA PARA

AFFILATE REGISTRATION NUMBER

Athlete’s portrait photos will gradually become compulsory for all FEI events. We therefore request a portrait photo of good quality from every rider/driver without helmet, hat or sunglasses against a neutral background that is applying for an FEI licence in 2016.

HAVE YOU ATTACHED A PORTAIT PHOTO: YES NO

(only needed if not send in previous years)

HAVE YOU COMPLETED THE MEDICAL QUESTIONNAIRE: YES NO

PLEASE INSERT YOUR EQUINE PREMISES NUMBER

AS ISSUED BY THE DEPARTMENT OF AGRICULTURE

FOOD AND MARINE

DECLARATION

I confirm that, to the best of my knowledge, all the information here is correct and there is no reason why this licence should not be granted. I have taken it upon myself to source and read the Horse Sport Ireland General Rules the (‘General Rules’) as well as Horse Sport Ireland’s Code of Conduct (“Code of Conduct”) and I confirm that I understood same. I confirm that I have read and understood the General Regulations, Statutes, Equine Anti-Doping and Controlled Medication Regulations and Anti-Doping Rules for Human Athletes of the Federation Equestre Internationale (“the FEI”) (I confirm that I agree to comply with and

be bound by Horse Sport Ireland’s General Rules, Horse Sport Ireland Code of Conduct and the General Regulations, Statutes, Equine Anti-Doping and Controlled Medication Regulations and Anti-Doping Rules for Human Athletes of the Federation Equestre Internationale (“the FEI”), as amended from time to time. I agree and confirm that while I am a registered Athlete of my discipline Affiliate and Horse Sport Ireland, I will be subject to, and will I comply with the aforementioned rules.

I consent to the use by Horse Sport Ireland in print, digital and electronic media, of photographic, sound and video images of me as an athlete, my image, my likeness and my name for the purpose of promoting Horse Sport Ireland. I confirm that Horse Sport Ireland may disclose Personal Information that it has collected regarding me to third parties where that information is of a general and biographical nature, in response to requests for information of this type, or as a part of Horse Sport Ireland public relations activities including placing this information on the Horse Sport Ireland website and Social Media Accounts.

Furthermore, as an Athlete, I consent and authorize Horse Sport Ireland to upload portrait photos to the FEI Database and in granting the said consent, I acknowledge that consent shall be deemed to be granted to the FEI for a worldwide, non-exclusive, perpetual licence to use, reproduce, distribute, prepare derivative works of, display my portrait photo in connection with the FEI activities, including without limitation for the purpose of promoting and redistributing my portrait photo in any and all media formats and through any media channels. Furthermore, I consent to the FEI displaying my date of birth on the FEI Database for the purposes of my Athlete Biography.

Furthermore, I understand that pursuant to the Data Protection Acts, 1988 and 2003 (the “DPA”), my consent is required for Horse Sport Ireland to process personal data which is may have in it’s procession concerning me including disclosure to third parties such as the Department of Agriculture Food and Marine and the Horse Sport Ireland Medical Officer, Dr Mary O’ Flynn Flannery. I note that this personal data may include sensitive personal data within the meaning of the DPA, the processing of which requires my explicit consent. As such, I consent to the processing of any information relating to me, either contained in this form or otherwise, for the purpose of issuing Athlete Licences and obtaining the necessary DOCOM Certificates pursuant to the Tripartite Agreement. Lastly, I understand that Horse Sport Ireland may disclose Personal Information that it has collected regarding me to third parties for the purposes of:

(a)investigating possible violations pursuant to the Horse Sport Ireland Equine Anti-Doping Rules and Equine Controlled Medication Rules, the FEI Equine Anti-Doping and Controlled Medication Regulations, FEI Anti-Doping for Human Athletes, and the Irish Anti-Doping Rules;

(b)administering and enforcing HSI Equine Anti-Doping and Medication Control Rules and the Irish Anti-Doping Rules;

(c)reporting on the administration and enforcement of HSI Equine Anti-Doping and Medication Control Policy, or the FEI Anti-Doping Rules for Human Athletes and FEI Equine Anti-Doping and Controlled Medication Regulations and the Irish Anti-Doping Rules, to governmental and non-governmental organisations who have a legitimate interest in anti-doping activities, in Ireland and elsewhere;

***A Parent or guardian must sign the above declaration in the case of minor (under 18)

Signature (Athlete): Print name (Athlete): Date:

Signature (parent/guardian): Print name (parent/guardian): Date:

LICENCE PAYMENT

  • Senior & Young Rider licence €175
  • Pony Rider & Junior licence €80
  • Single Event licence €80
  • Para Equestrian rider licences are free of charge

Please make cheques payable to Horse Sport Ireland or complete a separate Credit Card Form.Horse Sport Ireland will only process this application to the FEI once we have confirmed that the rider has no payments overdue to Horse Sport Ireland and that the rider is a member of the relevant affiliated body that runs the national aspects of their discipline or is a subscriber to the relevant Horse Sport Ireland section.

Please return the completed licence form and Declaration to Horse Sport Ireland to: Sport Department, Att.: Susann Killilea, Horse Sport Ireland, 1St Floor, Beech House, Millennium Park, Osberstown, Naas, County Kildare, Telephone +353 (0)45 854507, EMAIL –

Name:
Address: / Date of Birth:
Telephone No:
Mobile:
Fax:
E-mail:
Discipline: eg; Show Jumping, Eventing, Endurance, etc. / Next of Kin
Relationship to rider:
Next of kin’s address: / Next of kin’s
Telephone:
Mobile:
Fax:
E-mail:
G.P.’s Name and Address: / When did you last see your doctor?
When did you last receive a Tetanus Immunisation?
List any drugs you are currently taking (prescribed and over the counter). / List any herbs or vitamins you are currently taking. THIS IS VERY IMPORTANT.

Medical Questionnaire

To be completed and returned with FEI Athlete Licence Form

ANY CHANGE IN PRESCRIBED MEDICATION MUST BE NOTIFIED IMMEDIATELY

Signed:______Dated:______

Please return completed form ALONG WITH LICENCE FORM to e-mail: or post: Horse Sport Ireland, Att. Susann Killilea, 1st Floor Beech House, Millennium Park, Osberstown, Naas.

If you would rather send this form directly to our HSI medical officer Dr. Mary O’Flynn, then please Fax: 022-51708 or E-mail: