Randonneurs USA      Last Chance 2006 Application Form     Rocky Mountain Cycling Club

Name: __________________________________

Address: ________________________________

     _____________________________________

City: ___________________________________

State/Prov.: ____________ ZIP/Postal Code: ____________    

Country: ________________________________

Phone: (Day) ________________________

Phone: (Eve) ________________________

E-mail: ______________________________

RUSA member Nr: _________
Other Country Org. (e.g., Audax UK) / Member Nr.:
_________________________________________
DETAILS DISTANCES
  I will have a support crew.   1200km (US$150 base fee), or
  I am a UMCA John Marino Challenge participant.   1000km (US$150 base fee), and/or
  I am attempting to qualify for RAAM.   200km (no fee).
  Single bike     Tandem, partner: _____________________
QUALIFICATION - List brevets you have ridden in the twelve months prior to this year's event to qualify for the Last Chance. If you have ridden a higher-distance brevet to substitute for a lower distance or other agreed-upon substitute(s), note that to the left of the distance. If you are submitting payment prior to qualification, note "Pending Qualification" on the form and submit an updated form when you qualify.
Distance Date Location Elapsed Time Certificate Nr.
200km    
300km    
400km    
600km    
or 1000km    
     
     
WAIVER (please sign and date) - In signing below, 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, Ultra-Marathon Cycling Association, 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 and generally 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.

Signed (Rider, or Parent/Guardian if Rider is under the age of 18) ___________________________ Date ______________
Payment - by check or money order - is due with this application.

If paying in foreign currency, calculate your US$ amount, including the $10 surcharge, multiply by the exchange rate, and send that sum. For example, payment of the $150 base fee in Canadian dollars would be (US$150 + $US10) x 1.22 = 195.20 Canadian dollars.

Cancellations by Aug 1: full refund minus $10; Aug: 50%, Sept. 25%.

Base Cost Recovery Fee $150 ________
RMCC One-Year Membership (optional) $25 ________
RMCC Member Discount -$15 ________
Foreign-Currency Surcharge $10 ________
TOTAL US$ ________
Make check payable to Rocky Mountain Cycling Club.
Mail to: Rocky Mountain Cycling Club, Last Chance 1200k, P. O. Box 201, Wheat Ridge, CO 80034-0201 USA.