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tour de quisqueya - 2017 - registration form

I am registering as *

Cyclist Non-Cyclist

Non-cyclists: Please note that your spot will be confirmed upon closing of the open registration period. Since cyclists will be prioritized, we will keep your name on a first-come first-serve basis. Any funds you have paid as part of the registration process will be returned to you in the unfortunate event that you can not be accommodated. Thank you for understanding.

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 *

While we will do our best to accommodate your preference, please understand that this this can not be guaranteed. Note that single rooms can not be offered here but may be available upon arrival and based on availability. If you register as part of a group, we encourage you to maximize the occupancy per room. Thank you.

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

Please let us know your anticipated arrival date *

Option 1 & 3 - Friday February 17, Port-au-Prince (early / required for optional charter flight to Les Cayes) Option 1 & 3 - Saturday February 18, Port-au-Prince (regular arrival) Option 2 - Saturday February 25, Port-au-Prince (early) Option 2 - Sunday February 26, Port-au-Prince (regular arrival) other

Please let us know your anticipated departure date and location *

Option 1 - Sunday February 26, Port-au-Prince (early departure) Option 1 - Monday February 27, Port-au-Prince (regular departure) Option 2 & 3 - Sunday March 5, Cap Haitïen (early departure) Option 2 & 3 - Monday March 6, Cap Haitïen (regular departure) Option 2 & 3 - Tuesday March 7 or later, Port-au-Prince (late departure) other

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