Colorado High Country 2012 1200km Randonnee

Name:
Address:

City:
State/Prov.:	ZIP/Postal Code:
Country:

Phone:
E-mail:
Nationality:
Birthdate: Gender: Male Female
RUSA Nr: Membership Pending
Other Org.:
e.g., Audax UK

Emergency Contact:
Relationship:

E-mail:
Phone:

	Distance: 1200km 1000km	Recumbent Fixed Tandem, partner:
	I will have personal support.	I have completed these 1200k's:

QUALIFICATION - List brevets you have ridden since January 1 prior to this year's event to qualify for the High Country 1200. If you have ridden a higher-distance brevet to substitute for a lower distance or other agreed-upon substitute(s), note that under "Event Distance". If you are applying prior to full qualification, send an e-mail listing your remaining qualifying info when you've completed your qualification.

Distance	Date	Location	Elapsed Time	Certificate Nr.	Event Distance
200km
300km
400km
600km
or 1000km+

WAIVER - By submitting this application, I acknowledge that I understand this waiver’s intent, and I for myself, my heirs, executors, administrators, and representatives, do hereby agree and will absolve and hold harmless the Rocky Mountain Cycling Club, Randonneurs USA, Randonneurs Mondiaux, Audax Club Parisien, and any other parties connected with this event/these events in any way, from and against any blame and liability for any harm, loss, inconvenience or any other damage of any kind whatsoever, which may result from or be connected in any way from my participation in this event/these events. In addition to the absolute and unqualified release from all liability, I hereby represent that I am physically capable of participated in this event/these events; that my bicycle and any other equipment I may use is in good working condition; that I will observe all applicable traffic and event rules; and that I will wear a helmet while riding and conduct myself in a safe and prudent manner while participating in the event(s); that I undertake this ride as a personal bike tour and take responsibility for my own safety. I further agree to abide by the rules for riders of brevets. I certify that I have read this waiver and release and understand its significance.

Additional Remarks:

Submit your info electronically by clicking here.

Remember that you must both submit your application data (this form) and payment to get a reserved rider spot.