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Challenge Yourself & Raise Funds for Charity Guided tour From UCD to Eiffel Tower
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cyclechallenge ApplicAtion
Form
Challenge Yourself & Raise Funds for Charity Guided tour From UCD to Eiffel Tower
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• 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: [email protected]
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