ECA JR Kerst Block 2023-24 Application Form

Application deadline for 2023-24 ECA Kerst Block: 12 November 2023.

Full Name (as it appears on your passport):

Email Address:

Cell Number:

CX Racing Age (2023-24)

UCI ID (11 digit number on your USAC license page/account):

Date of Birth (day/month/year) E.g. 29 April 2004

USAC License #:

I hold a valid US passport (whose expiration date is AFTER March 1, 2024) and I have both a valid UCI 2023 license and will apply (on Dec 1, 2023) for a valid UCI 2024 license (in time for ECA Block). Please list Passport # and comment on abovementioned status for both passport and UCI 2024 license::

Your 2023-24 Official Cx Team Name: (note: in Europe, you will be racing for ECA):

Hometown & State:

ECA (Verge) Clothing:

Please list your sizing and specify Men's/Women's: --Long sleeve Jersey --Skinsuit --Bib Shorts --Thermal Jacket --Leg Warmers --Cx Pants --Socks

Parent(s) Names:

Parent(s) Email Address:

Parent(s) Cell Phone:

Coach Name:

Coach Email: