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REGULATION 21

SCHEDULE 4.

SCHEDULE 4

ACKNOWLEDGMENT AND AGREEMENT FORM

I, ....................................................... of .................................................... Union/Club/Rugby Body hereby acknowledge and agree as follows: 1.

I have received and had an opportunity to review the World Rugby [other] Anti-Doping Rules.

2.

I consent and agree to comply with and be bound by all of the provisions of the World Rugby [other] Anti-Doping Rules, including but not limited to, all amendments to the World Rugby [other] Anti-Doping Rules and all International Standards incorporated in the World Rugby [other] AntiDoping Rules.

3.

I acknowledge and agree that the World Rugby [other] has jurisdiction to impose sanctions as provided in the World Rugby [other] Anti-Doping Rules.

4.

I also acknowledge and agree that any dispute arising out of a decision made pursuant to the World Rugby Anti-Doping Rules, after exhaustion of the process expressly provided for in those Regulations, may be appealed exclusively as provided in Regulation [21.13] [*Appeals] to an appellate body for final and binding arbitration, which in the case of InternationalLevel Players [others] is the Court of Arbitration for Sport.

5.

The governing law of the appeal heard by the Court of Arbitration for Sport shall be English law.

6.

I acknowledge and agree that the decisions of the arbitral appellate body referenced above shall be final and enforceable.

7.

I agree that I will submit a Therapeutic Use Exemption form if I am required to do so under the World Rugby [other] Anti-Doping Rules;

8.

I agree that my personal anti-doping data relating to the Doping Control process (including test distribution planning, Sample collection and handling, laboratory analysis, result management, hearings and appeals), Therapeutic Use Exemption and/or player whereabouts can be processed (for example transmitted, disclosed, used and/or stored) by and amongst my [Union / club / rugby body], World Rugby, Member Unions, the World Anti Doping Agency (WADA), National Anti Doping Agencies and/or other Anti Doping Organisations (as applicable) in electronic form including but not limited to as part of the ADAMS 1 database system.

1

ADAMS is the Anti-Doping Administration and Management System which has been developed to enable athletes and anti-doping organisations to enter and share related to doping control. ADAMS is an on-line, webbased system, which allows restricted sharing of data only with those organisations with the right to access such data in accordance with the World Anti-Doping Code.

Last update: 3 January, 2017

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SCHEDULE 4

9.

REGULATION 21

I have read and understand this Acknowledgement and Agreement.

Date: ........................................................................................................... Print Name: ................................................................................................ (Last Name, First Name) Date of Birth: .............................................................................................. (Day/Month/Year) Signature: ................................................................................................... (or, if a minor, signature of legal guardian) *This form may need to be modified for local use

Last update: 3 January, 2017

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