Application Form Dublin-Paris Challenge

cycle Application challenge

Form

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

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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

Sponsorship required for participation: €2500 per person or €4 per Km (Approx) • Accommodation on per person sharing basis, 4 nights in hotels & 1 night in en suite cabin on ferry • • Meals, 4 breakfasts, 5 lunches, 5 dinners, snack stops/ feed stations on route • Luggage transfers between hotels, ferry, back up van • Service of an experienced guide on the bike on approximately 1:10 basis • Service of an experienced bike mechanic • Transport of your bike back to Dublin • Training programme and tips from qualified coach • Flight home from Paris

Dublin-Paris Challenge 17-22June 2012

Title

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Name(s) ______________________ Surname ______________________ Address

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______________________ ______________________ Date of Birth (must be over 18) _________ Sex (M/F)

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Phone (day)

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Phone (mob)

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Fax

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Email address ______________________ 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

next of kin: Title

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Name(s) ______________________ Surname ______________________ Address

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______________________ ______________________ Relationship ______________________ Phone (day)

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Phone (mob)

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personal details

Do you have any special dietary requirements?

Yes/No If yes, please give details. Please note we can only cater for allergies not preferences ____________________________________________ ____________________________________________ ____________________________________________

Are you a smoker? Yes/No ___________________________________________

Please note: All accommodation will be shared Do 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

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).

Dublin-Paris Challenge 17-22June 2012

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: __________________________________

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 Credit Card Number

VISA

MASTERCARD

LASER Exp Date CVV No

Name of Card Address Of Cardholder

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

Please return your completed application form plus deposit to:

Outreach Moldova. Suite 104 DMG House, Deansgrange Business Park, Deansgrange, County Dublin.

Web: www.outreachmoldova.org

Tel: (01) 219 0268

E-mail: moldova@ireland.com