Colorado Last Chance 1200 - 2017 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.:
_________________________________________
Distance:   1200km   or    1000km   Recumbent      Fixed     Tandem, partner: ______________________
  I will have personal support .   I have completed these 1200k's: ________________________________________

Emergency Contact: __________________________________

Relation: ________________________________

E-Mail: _________________________________________

Phone: __________________________________________

QUALIFICATION - List brevets you have ridden since September 1, 2012 to qualify for the Last Chance 1200. If you have ridden a higher-distance brevet to substitute for a lower distance or other agreed-upon substitute(s), note under "Event Distance" If you are submitting payment prior to qualification, note "Pending Qualification" and mail/e-mail a list of your qualifying rides when you finish qualifying.
Distance Date Location Elapsed Time Certificate Nr. Event Distance
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, 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.

Signed (Rider, or Parent/Guardian if Rider is under the age of 18) ___________________________ Date ______________

Payment of $225 (USD) is due with this application.

You may pay online (preferred)
or by check or money order in US dollars. — Make check or money order payable to Rocky Mountain Cycling Club.
If paying by check, include that with your application.

Mail this application to: Colorado Last Chance 1200, 3936 Dale Drive, Lafayette, CO 80026, USA