Stad&Ommelandtocht

Registration

N.B. Fields with (*) have to be filled in. Please enter one registration for each participant.

NAME AND ADDRESS
Contact person	man woman
* Initials/Middle Name/ * Name
* Street / * number
* Zipcode /* Town
* Land
PERSONAL DATA
* Telephone number
Telephone number in case of accident
* E-mail address
* Date of birth
Place of birth
DATA CONCERNING PARTICIPATION
* Age category	younger than 4 years (� 20,00) 4 till 11 (� 40,00) 12 years and older (� 100,00/� 125,00)
I am member of	BCU CCC N.B. Members of BCU/CCC -older than 12- pay the lowest price.
Membership number (if applicable)
Name of Canoe Club
* Transport of luggage wanted	Ja (� 35,00) Nee N.B. Tot 12 jaar is transport gratis!
* I can swim	Yes No N.B. Obligatory when participating independently!
Number of times I participated before
Name parent/attendant (of minor)	N.B. Parents/attendants of minors receive a letter to subscribe!
Questions/Remarks
*Did you fill in the obligatory () fields? Then click 'Send'**