[Ct-nfb] FW: fishing

[Elizabeth Rival]

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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