La Bicicletta Grand Prix Entry Form

Event dates: June 8-9, 2002

To register for the La Bicicletta Grand Prix cycling race, use the ONLINE REGISTRATION or fill out the form below and mail with your payment to: Midweek Club c/o Peter McCaffery, 1249 Woodhill Court, Mississauga ON, L5E 3H1

The registration fee is $75. Before May 15th. or $90 after May 15th. and before June 1st.

N.B.: NO RACE DAY ENTRIES FOR SENIOR 1/2 EVENT

Name/Nom:

Phone #/# de tél:

E-mail Address/Courriel:

Address/Adresse:

City/Ville:

Province/State:

Postal Code/Zip Code:

Country/Pays :

Age/Âge:

Date of Birth/Date de naissance: Year/Annee:

Register for which race/Inscription pour quelle course:

Senior 1 and Senior 2 Men's/Hommes (amateur and professional racers over 19 years/amateur et professionnel de plus de 19 ans). Note: must enter as a team of 6 riders. No individual entries. Teams may use senior 3 or master A if necessary.

Senior 3 Men's/Hommes (19-29 year old racers not currently qualified to race Sen 1 or 2 events/19-29 ans non qualifié pour la course Senior 1 ou 2)

Veteran A Men's/Hommes (30-39 years/ans)

Veteran B Men's/Hommes (40-49 years/ans)

Veteran C Men's/Hommes (50 plus years/ans)

Juniors (16-19 years/ans)

Women's/Femmes (all ages race together/toutes âges même catégorie)

CCA/AAC Licence:

Club:

Medical Alerts/Allergies/Problèmes médicaux/allergies:

Emergency Contact & Phone /Contact en cas d'urgence et telephone: