Name: __________________________________ |
Phone: _________________________________________ E-mail: __________________________________________ Nationality: _________________________ Birthdate: _____________ Gender:____ RUSA member Nr: _________ Pending
|
Distance: 1200km or 1000km |
Recumbent
Fixed
Tandem, partner: __________________________
I will have personal support .
|
I have completed these 1200km+ Grand Randonnées: ________________________________________
|
| Additional Remarks (including dietary restrictions, etc.):
____________________________________________________________________________________
| ____________________________________________________________________________________ ____________________________________________________________________________________ |
Emergency Contact: __________________________________ |
E-Mail: _________________________________________Phone: _______________________________________ |
Distance | Date | Location | Elapsed Time | Certificate Nr. | Event Distance |
200km | |||||
300km | |||||
400km | |||||
600km | |||||
or 1000km+ | |||||
Mail to:
Rocky Mountain Cycling Club
c/o Beth Long, Treasurer
686 S Poplar St
Denver, CO 80224 USA.