CCE application form

CCE 2010 Program Application Form

Click (or tab) in each field and type in your information, then press the "submit" button. If you do not hear from us within two weeks, please contact us at: info@strawberryfields.org.

If you are in need of financial assistance to participate in this activity, in addition to your application form, please send a letter or e-mail to the CCE committee: info@strawberryfields.org with your name, address, the amount of assistance you may require, and brief description of your needs. Your information will remain confidential.

Personal Information

First Name	Last Name
YOU ARE	Birth Date
Street Address	City Name
State /Province	COUNTRY	Postal Code
E-mail Address	Telephone
Passport number
Emergency Contact	Emergency phone
Please specify which program you are interested in

Your blood type, allergies, medicines, other medical conditions:

Technical and Physical Conditions

Average distance you can ride in one day:	more than 150 km	100 km	50 km
Your average speed:	30 km/h and more	15 km/h	less than 15km/h
Your physical fitness:	very good	good

Touring skills
Ability to camp:	excellent	good	none
Ability to cook:	excellent	good	none
First Aid skills:	yes	no

Social Agility
English languge skills:	advanced	basic	none
Other languages (please include skill level):
Are you are smoker?	yes	no
Do you have experience traveling with a group?	extensive	some	none

Other group experiences:

Your reasons to participate in CCE program: