docUltra ASIA Race 2017 - Registration Form - Canal
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Ultra ASIA Race 2017 - Registration Form - Canal
Registration Form 1/2 Personal informa.on Surname: Sex: M. First Name: Date of birth: Na.onality: Profession: Shirt Size: Bio (Informa.on for your compe.tor profile): Address: Zip/Postal Code: Town: Country: Email: Phone n°: Cell phone n°: Person to be contacted if emergency Surname: First Name: Email: Phone n°: Cell phone n°: The Track Organisa.on (T.T.O.), 21 Rue du Contrat Social 76 000 Rouen -‐ FRANCE Tel: +33 2 35 70 15 42 -‐ Email: contact@canal-‐aventure.com – www.canal-‐aventure.com Opérateur de voyages et de séjours N° IM076130003 Assurance: MMA IARD, 14 Boulevard Marie et Alexandre Oyon -‐ 72 030 Le Mans Cedex 9 -‐ FRANCE Garant: Groupama Assurance-‐Crédit, 5 rue du Centre – 93 199 Noisy-‐Le-‐Grand Cedex -‐ FRANCE F. Registration Form 2/2 Have you a Canal Aventure member like sponsor? Yes No If yes, specify its name and membership number: N° 1 300 Euros if registering before the 27 September 2016 REGISTRATION Deposit of 800 Euros / Balance due no later than 100 days before the event 1 600 Euros star.ng the 27 September 2016 Deposit of 800 Euros / Balance due no later than 100 days before the event I declare that I have read the regulaRons of the Ultra ASIA Race organized from 27 to 30 March 2017, by The Track OrganisaRon and that I accept these without reservaRon. I declare that I take part at the Ultra ASIA Race in full knowledge of the risks that this compeRRon may entail. To be registered definitely, I agree to pay the full registraRon fee no later than 100 days before the event. I also agree to provide the official medical cerRficate for the Ultra ASIA Race and an electrocardiogram report at state of rest, validated under 30 days before the race start, during the administraRve and technical checks Pre-‐race. I guarantee that all personal details provided on this registraRon form are correct. Place: Date: Signature preceded by the words "read and approved". Cancella.ons ( Voir ART. 18) • If noRce of cancellaRon is received 100 days or more before event, you will receive a refund of the total fees you have paid less 500 Euros. • No fees will be refunded for any cancellaRon received less than 100 days before an event. The Track Organisa.on (T.T.O.), 21 Rue du Contrat Social 76 000 Rouen -‐ FRANCE Tel: +33 2 35 70 15 42 -‐ Email: contact@canal-‐aventure.com – www.canal-‐aventure.com Opérateur de voyages et de séjours N° IM076130003 Assurance: MMA IARD, 14 Boulevard Marie et Alexandre Oyon -‐ 72 030 Le Mans Cedex 9 -‐ FRANCE Garant: Groupama Assurance-‐Crédit, 5 rue du Centre – 93 199 Noisy-‐Le-‐Grand Cedex -‐ FRANCE
