Colorado Last Chance - 2010 Application Form    
— Print this form; fill it in; and mail it with a check to address below. —

Name: __________________________________

Address: ________________________________

     _____________________________________

City: ___________________________________

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

Country: ________________________________

Phone: _________________________________________

E-mail: __________________________________________

Nationality: _________________________

Birthdate: _____________    Gender:____

RUSA member Nr: _________ Pending
Other Country Org. (e.g., Audax UK) / Member Nr.:
_________________________________________
  I will have a support crew.   1200km   or     1000km
  I am a UMCA Ultracycling Cup Competition participant.   I have completed these 1200k's: ______________________________
  I am attempting to qualify for RAAM.   Recumbent      Fixed     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 under "Subst Dist." If you are submitting payment prior to qualification, note "Pending Qualification" and submit an update when you finish qualifying.
Distance Date Location Elapsed Time Certificate Nr. Subst. Dist.
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, Randonneurs Mondiaux, 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 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 ______________

Front - click to enlarge
JERSEY/VEST ORDERS  Men's     Women's 
  S M L XL Price Qty. Ext. Price
Short Sleeve Jersey $79 ___ $____
Sleeveless Jersey $79 ___ $____
Wind Vest $73___ $____
Thermal Vest $89___ $____
TOTAL $____ 
Voler sizing chart - click on "sizing" tab.

Back - click to enlarge.

— Calculate Payment Below —
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 $185 base fee in Canadian dollars would be (US$185 + $US10) x 1.25 = 243.75 Canadian dollars.

Cancellations by July 31: full refund less $10; Aug 1-31: 50%, by Sept. 8: 25%.

Base Cost Recovery Fee $185 _$185___
RMCC One-Year Membership (optional) $25 ________
RMCC Member Discount -$15 ________
Foreign-Currency Surcharge $10 ________
Jerseys/Vests ________
TOTAL (including Jerseys/Vests) US$ ________
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.