CCE 2009 Program Application Form

Click (or tab) in each field and type in your information, then press the "submit" button. 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 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: