[Ct-nfb] FW: fishing
Elizabeth Rival
erival at comcast.net
Fri Apr 13 14:09:08 UTC 2012
Brought to you free by the Lyons club of Berlin. Beth
From: Elizabeth Rival [mailto:erival at comcast.net]
Sent: Sunday, March 18, 2012 3:56 PM
To: rachriste1 at cs.com
Cc: 'Elizabeth Rival'
Subject: fishing
HI, pasted below. Beth VIPAPPLICATION-seniorslogo (2).pdf
5
Senior Tournament VIP and Volunteer Application
CT VIP Fishing Tournament
April 22, 2012
Sage Park Pond, Berlin, CT
Instructions: Each VIP will be allowed one sighted "companion" for
assistance during the event. All attendees
are required to complete this form. VIP participants will be accepted on a
first come, first serve basis as we are
limited to 30 participants for this event.
O Sighted Guide
Name:
Last Rival :___________________________________________________First
Elizabeth :_______________________NickBeth . name:_____________
Address:
Street33 Parish Drive
____________________________________________________________________________
________PO BOX________
City Kensington _____________________________________________State CT.
_______ZipCode 06037 __________
Phone Number:
Home 860 828 8378 _____________________ Work 860 289 1971
_________________Cell 860 916 0459 __________________
E-mail address erival at comcast.net_______________________________
Date of Birth 3/31/53 ____________________________ Sex (Circle One) F
Are you a Lion? (Circle One) N If so, which club__________________
Do you have a preferred "companion" to assist you during the event?
Companions Name Charlie Rival
________________________________________________________
Circle One: Totally Blind
Do you use a seeing eye dog?
Do you have special equipment or dietary needs: If so, what no no ?
_______________________________________________________
List any medical problems and or medications taken on a regular basis. (Use
the back of this page or attach list) no
Emergency Contact:
Name Kim Rival ________________________________________________Phone 860
978 2411 _______________________________
Please promptly return the completed application to Lion Bob Christensen,
275 Lower Lane, Berlin, CT 06037.
For more information please contact me at (860) 680-7227 or by e-mail at
rachriste1 at cs.com
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