cyclechallenge ApplicAtion

Form

Challenge Yourself & Raise Funds for Charity Guided tour From UCD to Eiffel Tower

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

-- -

- - -

- - -

- - -

- - -

- - -

- - -

• Accommodationonperpersonsharingbasis,• 4nightsinhotels&1nightinensuitecabinonferry• Meals,4breakfasts,5lunches,5dinners,snackstops/feedstationsonroute• Luggagetransfersbetweenhotels,ferry,backupvan• Serviceofanexperiencedguideonthebikeonapproximately1:10basis• Serviceofanexperiencedbikemechanic• TransportofyourbikebacktoDublin• Trainingprogrammeandtipsfromqualifiedcoach• FlighthomefromParis

Sponsorship required for participation: €2500 per person or €4 per Km (Approx)

• Fully supported with experienced guides • Luggage Transport • Bikes Transported back to Dublin • Meals & Feed Stations • Beautiful Quiet Road & Stunning scenery • 2 Days in Ireland • 3 Days in France

Dublin-Paris Challenge 17-22June 2012

Personal Details

Title ______________________

Name(s) ______________________

Surname ______________________

Address ______________________

______________________

______________________

Date of Birth (must be over 18) _________

Sex (M/F) ______________________

Phone (day) ______________________

Phone (mob) ______________________

Fax ______________________

Email address ______________________

next of kin:

Title ______________________

Name(s) ______________________

Surname ______________________

Address ______________________

______________________

______________________

Relationship ______________________

Phone (day) ______________________

Phone (mob) ______________________

During the fundraising time before the cycle your fellow cyclists may wish to contact you. If you agree to have your phone number and/or address shared with the other cyclists ONLY Please tick the following box

Outreach Moldova (ORM) offer this chance to participate in the Dublin Paris Cycle Challenge as a fun filled but strenuous physical challenge. You should ensure that you are in good physical health before embarking on the challenge.

By agreeing to participate you are committing to target a total sponsorship of between €2000 and €2500 per participant. This will cover all the costs associated with the tour, including accommodation, cycle guides and mechanics, ferry passage, hotels on a DB&B basis and all meals as noted in the brochure and one way air fare from Paris to Dublin with Ryanair (voucher value €75).

Please note: All accommodation will be sharedDo you have a preference for who you wish to share with? Yes/No

Please specify name_____________________________

A limited number of single rooms may be available; there will be an additional single supplement charge of €195 Yes/No

Do you have any special dietary requirements? Yes/NoIf yes, please give details. Please note we can only cater for allergies not preferences____________________________________________________________________________________________________________________________________

are you a smoker? Yes/No___________________________________________

_________________________________________________________________________________________

I have read and agree to abide by the Rules and Regulations in the accompanying document which I understand may change from time to time and I will be contacted on the above email address with. I also acknowledge Final payments must be received by May 15th 2012

i am aware that this is a physically demanding event which requires training and i have discussed the implications of taking part in the event and training with my doctor.

Signed: _________________________________ Date: __________________________________

Dublin-Paris Challenge 17-22June 2012

Please return your completed application form plus deposit to:outreach Moldova. suite 104 DMG House, Deansgrange Business Park,

Deansgrange, County Dublin.

Participation in the cycle is at the sole discretion of ORM & Irish Cycling Safaris

Payment details - Deposit for booking this challenge is €300 I enclose a cheque for the amount of €300 made payable to ORM

Please charge €300.00 to my Circle as appropriate

VISA MASTERCARD LASER

Credit Card Number Exp Date CVV No

Name of Card

Address Of Cardholder

Web: www.outreachmoldova.org tel: (01) 219 0268 e-mail: moldova@ireland.com

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

-- -

- - -

- - -

- - -

- - -

- - -

- - -