MID ATLANTIC
12/24
Event Registration

Mid Atlantic 12/24 UMCA Event & Century

24 hour RAAM Qualifier

Registration:

Name: ___________________________             Last Name: _________________________

 

Address: _______________________________________________________________

 

City: _____________________ State: ____  Zip: ________  Country: _____________

 

Phone: ____________________   DOB: _______ Gender: Male (   ) Female  (   )

 

Email: _________________________________________________________________

 

Bicycle Type:        Standard (  )         Recumbent (   )     

 

Tandem (  )            HPV (   )                 Hand Cycle (  )

Tandem partners name: __________________________                                

 

 

Registration for:          12 Hour (  )            Century (  )

            24 Hour (  )            Non Competitive Century (  )

 

UMCA MEMBER?                Yes (   )   No (   )    #: ________________________




Entry Fee (After 7/30 price increase of $10 per division)

$90 Per 24 Hour Rider       $60 Per 12 Hour Rider        

$30 Per Century Rider         $25 Per Non Competitive Rider         

 **TANDEM RIDERS: PLEASE INCLUDE $10 UP CHARGE ON DIVISION OF CHOICE TO COVER 2ND RIDER**


Tee Shirt Selection:

Men: ____Small  ____Med  ____Large  ____XL  ____other


Women:  ____XSmall  ____Small  ____Med  ____Large  ____XL  ____other


Make check payable & Mail to:

Mid Atlantic Ultra Sports
724 Old Bath Highway
Washington
, NC 27889

 
Submit a separate registration form for each rider.  You must also sign a waiver at check in.

HELMETS ARE MANDATORY.  Parent or Guardian must sign for minors (under 18 years old).

 

Cyclist’s Printed Name: _________________________________________________________

 

Cyclist’s Signature: _______________________________________ Date: ________________

 

Signature of Parent or Guardian

If cyclist is under 18:____________________________________________________________

 

 

 

WWW.MIDATLANTICULTRASPORTS.COM | 252-945-9495

 

 

 

If registering via USPS please print and submit above form or visit BikeReg.com for online registration.

All events are held rain or shine and entry fees are non refundable and non transferable.



1.800.336.1977
www.hammernutrition.com
Website Builder