Declaration of Health

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IF YOU ARE A FIRST-TIME RIDER YOU MUST ALSO COMPLETE A BHA MEDICAL (unless you have had one as an amateur in the last 5 years)

Name(Required)

Title First Last

Date of Birth(Required)

Age

Height in cm(Required)

Riding Weight (kg)(Required)

Non Riding Weight (kg)(Required)

GP Name(Required)

GP Address(Required)

Street Address Address Line 2 Town / City County Post Code Country

Date of Last BHA Examination(Required)

Have you held an amateur riders permit with the BHA or any other turf authority in the past?(Required)

Yes

Do you currently hold a medical record book issued by the British Horseracing Authority, HRA or The Jockey Club?(Required)

Yes

Have you ever had a licence or permit refused or deferred in Point-to-Point racing or Under Rules on medical grounds?(Required)

Yes

Date of refusal / Date of deferment(Required)

Date of reinstatement (if applicable)

Are you currently disqualified or an excluded person with the BHA or Any other recognised turf authority?(Required)

Yes

Declaration of Health

Please list ALL operations, hospital admissions, head injuries/concussions, fractures and dislocations that you have EVER suffered together with dates (including any unconnected with racing)

INJURY/ILLNESS/OPERATIONS

Injury / Illness / Operation

Details (Location / Operation /Hospital Admissions

Date

Please list ALL operations, hospital admissions, head injuries/concussions, fractures and dislocations that you have EVER suffered together with dates (including any unconnected with racing). SELECT + TO ADD MORE ROWS

Please list all injuries and serious illnesses (requiring medical attention that you have suffered since last RQC including any unconnected with racing)

Injuries and serious illnesses

Date

Please list ALL medications you are currently taking or have taken for more than 14 consecutive days in the last 12 months (excluding the contraceptive pill)

Medications

Date Started

Have you ever suffered from concussion?(Required)

Yes

Date of concussion

Please give details about your concussion(s)

ALL CONCUSSIONS WILL REQUIRE A BHA POST CONCUSSION TEST

Have you ever had a baseline concussion test?(Required)

Yes

Date of baseline concussion test

Location of baseline concussion test

Have you ever had your driving licence revoked or suspended for medical reasons?

Yes

Do you have a valid drivers licence?

Yes

Within the last five years have you received treatment, counselling or sought medical attention for any condition related to alcohol or drug consumption?

Yes

Please provide details

Your Application for a Riders Qualification Certification cannot be processed unless all relevant medical details are given within this form.

Statements like ‘Please see Medical Record Book’ or ‘Please refer to previous Application’ are not sufficient.
All riders falling into the following categories will also be required to submit a completed BHA Medical Form (NMED19)
before a certificate is issued:

All first-time applicants.
Every 5 years there on in.
Applicants aged 40+ require a medical every 2 years on the date of application being logged.
Applicants aged 50+ require a medical every year on the date of application being logged.
Applicants aged 55+ on the date of application will also be required to provide: a resting 12 lead ECG and blood tests for FBC, liver and renal function, fasting lipid profile and glucose.

Please note: In addition to the above categories, applicants may be required to submit subsequent BHA medical forms at the discretion of the BHA Chief Medical Advisor/PPA Medical Advisor and in consideration of the rider’s medical history.

For all riders who hold a current Amateur Rider’s Permit to ride under Rules, the Medical arrangements under Rules will always take precedence over the medical screening for Point-to-Points. Under these circumstances, riders will have a medical carried out as required for Amateur Riders by the Licensing Committee of The British Horseracing Authority and do not need to have additional examinations to satisfy the British Horseracing Authority Point-to-Point Regulations. Should you have any queries, please contact:The Point-to-Point Authority on 01793 781990.

MEDICAL CONSENT
In this form we have asked you to supply personal information such as your contact and health details. We may also collect further information from you during the season, for example if you are injured in a fall. We may keep a record of any injuries and medical conditions from which you suffer. We may also seek medical information from the British Horseracing Authority, further to your consent in your Application for a Riders Qualification Certificate.

The information we collect about you (and that collected about you in previous years) may be used in the following ways:

to assess your fitness to ride in Point-to-Points.
to assess your compliance with the BHA Regulations and Instructions for Point-to-Point steeplechases from time to time in force.
to manage your rider’s qualification certificate for Point-to-Point and any licence(s) for racing under other BHA rules and/or your medical record book(s).
to perform our contractual obligations in relation to the promotion and administration of P2P (the BHA retaining responsibility for its regulation).
to help to ensure your safety and the safety of others in any activities in which you take part. For example, if you suffer a fall during a Point-to-Point, we may use information about your health and medical conditions to ensure that you receive the appropriate care.
to enable us to contact you in relation to surveys about health and medical issues (following disclosed injuries or medical conditions) and/or fitness to ride.
to collate injury and health information to help us to manage medical arrangements and safety at Point-to-Points generally and arrange training for Point-to-Point doctors, paramedics, clerks of the course and secretaries.
to provide information to the PPA’s insurance brokers and/or insurers for the purposes of obtaining insurance and/or processing any claim under that insurance.
We may also share information with third parties as follows:
- with doctors, paramedics and nurses, to include Point-to-Point Doctors and paramedics, the PPA Medical Advisor, the BHA’s Chief Medical Advisor and racecourse Medical Officers, but only where this is necessary for the purposes described above.
- with the BHA and other recognized racing authorities such as the Turf Club for the purposes described above, but only where this is necessary.
- with the PPA’s insurance brokers and/or insurers for the purposes described above, but only where this is necessary.
- where we have a legal obligation to do so.

N.B. Supplying false or incomplete information will put you in breach of Regulations 170 (v) and (vi) of the British Horseracing Authority Regulations for Point-to-Point Steeple Chases 2020/21.

ANY CHANGE IN YOUR MEDICAL STATUS SUBSEQUENT TO THE ABOVE DATE MUST BE ADVISED TO THE BHA’S CHIEF MEDICAL ADVISOR IN WRITING OR BY EMAIL medical@britishhorseracing.com OR BY FAX ON 0207 152 0136.

You are reminded that ALL riders who suffer a concussion will be suspended and will not be allowed to return to race riding until they are cleared by The British Horseracing Authority Medical Department after completing the Concussion Protocol. Your return to riding timescale is likely to be quicker if you already had a baseline concussion test result. Should you be interested in undergoing the optional baseline testing procedure further details are available from:

The Medical Department of the British Horseracing Authority on 0207 152 111.

Next of Kin

Next of Kin Phone Number

Next of Kin Alternative Number

Next of Kin's Relationship to You

Private medical Insurance can really help when looking after injured jockeys in the longer term.

Do you have Private medical insurance?

Yes

This is only applicable if it is for equestrian accidents, including racing:

Acceptance of Risk

I acknowledge that when riding under the British Horseracing Authority Regulations for Point-to-Point Steeple Chases, there is a very high risk of injury to me in comparison to other sporting activities and that such a risk can come from other riders and horses. I accept that by taking part in amateur horseracing under the British Horseracing Authority Regulations for Point-to-Point Steeple Chases my physical safety could be endangered and that neither the British Horseracing Authority nor the organisers have a responsibility to assess the skill and experience of riders and horses taking part. However, I confirm that I believe myself to be a competent rider who has schooled over fences and is capable of riding in Point-to-Point Steeple Chases.

By signing the declaration below, I hereby consent for the British Horseracing Authority (“BHA”) to release to the PPA any medical information held by it related to my application for a Riders Qualification Certificate or my future fitness to ride (the “BHA Records”), and that the BHA Records shall only be shared where necessary. Once shared, I understand that the PPA shall be principally responsible for ensuring protection of the BHA Records in accordance with the Data Protection Act 2018 and the medical consent provisions in this form. I understand that if I ever wish to revoke my consent for the BHA to share the BHA Records, I must notify the BHA and PPA in writing of that fact. I undertake to notify the PPA within 7 days of any change to my home address, mobile or home phone number.

I have read the above statement and accept the risks associated with riding in Point-to-Points

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Declaration

I confirm that I am in good mental and physical health and I know of no condition that would currently preclude me from riding in Point-to-Points. I declare that the information provided on this form is complete and true, to the best of my knowledge. By signing this declaration, I agree to my personal information held by the PPA and/or provided in this form being used and disclosed as described above.

I have read and agree with the above statement about my health

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Declaration Date

Applicants under 18 years of age must provide a signed consent letter from a parent/guardian stating that they are happy for you to ride in in Point-to-Points. Please upload your signed letter below.

Under 18 Parental Consent

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