formularz MTB_GrandPrix.ai

LANG TEAM GRAND PRIX MTB 2013 notification form
Cyclist details
Club
Category
* Start No.
Last Name
Bicycle make
First Name
* Date of medical examination
UCI code
Residence address
Postal code
License No.
* To be filled in by the Jury Panel; the Jury Panel checks the valid medical certificates and assigns a start number
City
Street
House no.
Province
Flat no.
Country
Signature of custodian, trainer, cyclist (if of legal age)
Contact phone
e-mail
Please send the completed
form to the address:
Lang Team Sp. z o.o.
Biuro Organizacji
Imprez Sportowych
ul.Pachnąca 81, 02-792 Warszawa
tel. +48 22 649 24 91/96
fax +48 22 649 24 98
[email protected]
DATES AND PLACES OF EDITION:
28.06.2013 - JELENIA GÓRA
MTB SPRINT
30.06.2013 - JELENIA GÓRA
TROPHY MAJA WŁOSZCZOWSKA
MTB RACE
Declaration
I hereby declare that I have read the Lang Team Grand Prix MTB regulations
and I undertake to comply with them. I am in a good health condition and Legible signature of the cyclist
there are no medical and general contraindication as to my participation in
the competition. I take part in the competition at my own risk.
Information Clause:
Please be informed that the personal details provided in this form will be administered by Lang Team Sp. z o.o. with its registered office in Warsaw, ul.
Pachnąca 81. The details will be processed according to the act of 29 August 1997 on personal data protection (uniform text Journal of Laws 2002 No.
101, item 926 as amended) for purposes related to the participation in the race as well as for archiving, information, marketing and promotional
purposes. Provision of the above details is voluntary but necessary to participate in the race.
Consent Clause:
I hereby consent to process my personal data collected by Lang Team Sp. z o.o. with its registered office in Warsaw, ul. Pachnąca 81, and to
use my image for purposes indicated here above.
Date and legible signature of the cyclist