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I am registering as *

Cyclist Non-Cyclist

Gender *

Male Female

Which Option do you choose? (you can specify alternate dates later) *

Option 1 - The South of Haiti (Feb 18 to 27) Option 2 - The North of Haiti (Feb 26 to March 6) Option 3 - Haiti South to North (Feb 18 to March 6)

Name *

First

Last

Date of Birth *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Please Upload a Picture of Yourself *

Max file size: 20MB

This will be my first visit to Haiti *

Yes No

I am part of a group *

Yes, with other cyclists Yes, with other cyclists and non-cyclists Yes, with other non-cyclists No, I am registering alone

# of additional registrants *

Lodging Preference *

Jersey / T-Shirt size *

I have read and agree to the Liability Waiver *

Yes

I have paid the registration fee *

In full (online) Down Payment online (I will pay the remainder by Nov-15) Down Payment online (I would like to fund raise for the remainder - please create a fund raising page for me) In full (check mailed) Down Payment, check mailed (I will pay the remainder by Nov-15) Down Payment, check mailed (I would like to fund raise for the remainder - please create a fund raising page for me)

Date check was mailed: *

About your bicycle for the Tour... *

Bring my own at own expense on international flight (round-trip) Bring my own at own expense on international flight (will leave it as a donation) Rent a bicycle from the Léogâne Cycling Club (subject to availability, $300 per week)

If you are interested in renting a bike from us, please give us your frame size (subject to availability) *

Anything else we should know (e.g. dietary constraints) or questions you may have? *

Please let us know which optional activities you tentatively wish to participate in *

Option 1 & 3 - Charter flight from Port-au-Prince to Les Cayes (must arrive early on February 17) Option 1 & 3 - Hike the Seguin Plateau Option 2 & 3 - Visit Partners in Health Clinic in Mirebalais I don't know yet

If other, please specify you tentative plans - we will try to accommodate with transfer service *

By providing your electronic signature you agree to all terms & conditions and verify that the above information is correct *

tour de quisqueya registration

tour de quisqueya - 2017 - registration form