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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link=blue vlink=purple><div class=WordSection1><p class=MsoNormal><span style='color:#1F497D'>Brought to you free by the Lyons club of Berlin. Beth <o:p></o:p></span></p><p class=MsoNormal><span style='color:#1F497D'><o:p> </o:p></span></p><div><div style='border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in'><p class=MsoNormal><b><span style='font-size:10.0pt;font-family:"Tahoma","sans-serif"'>From:</span></b><span style='font-size:10.0pt;font-family:"Tahoma","sans-serif"'> Elizabeth Rival [mailto:erival@comcast.net] <br><b>Sent:</b> Sunday, March 18, 2012 3:56 PM<br><b>To:</b> rachriste1@cs.com<br><b>Cc:</b> 'Elizabeth Rival'<br><b>Subject:</b> fishing <o:p></o:p></span></p></div></div><p class=MsoNormal><o:p> </o:p></p><p class=MsoNormal>HI, pasted below. Beth VIPAPPLICATION-seniorslogo (2).pdf<o:p></o:p></p><p class=MsoNormal>5<o:p></o:p></p><p class=MsoNormal>Senior Tournament VIP and Volunteer Application <o:p></o:p></p><p class=MsoNormal>CT VIP Fishing Tournament <o:p></o:p></p><p class=MsoNormal>April 22, 2012 <o:p></o:p></p><p class=MsoNormal>Sage Park Pond, Berlin, CT <o:p></o:p></p><p class=MsoNormal>Instructions: Each VIP will be allowed one sighted “companion” for assistance during the event. All attendees <o:p></o:p></p><p class=MsoNormal>are required to complete this form. VIP participants will be accepted on a first come, first serve basis as we are <o:p></o:p></p><p class=MsoNormal>limited to 30 participants for this event. <o:p></o:p></p><p class=MsoNormal>O Sighted Guide <o:p></o:p></p><p class=MsoNormal>Name: <o:p></o:p></p><p class=MsoNormal>Last Rival :___________________________________________________First Elizabeth :_______________________NickBeth . name:_____________ <o:p></o:p></p><p class=MsoNormal>Address: <o:p></o:p></p><p class=MsoNormal>Street33 Parish Drive ____________________________________________________________________________________PO BOX________ <o:p></o:p></p><p class=MsoNormal>City Kensington _____________________________________________State CT. _______ZipCode 06037 __________ <o:p></o:p></p><p class=MsoNormal>Phone Number: <o:p></o:p></p><p class=MsoNormal>Home 860 828 8378 _____________________ Work 860 289 1971 _________________Cell 860 916 0459 __________________ <o:p></o:p></p><p class=MsoNormal>E-mail address erival@comcast.net_______________________________ <o:p></o:p></p><p class=MsoNormal>Date of Birth 3/31/53 ____________________________ Sex (Circle One) F <o:p></o:p></p><p class=MsoNormal>Are you a Lion? (Circle One) N If so, which club__________________ <o:p></o:p></p><p class=MsoNormal>Do you have a preferred “companion” to assist you during the event? <o:p></o:p></p><p class=MsoNormal>Companions Name Charlie Rival ________________________________________________________ <o:p></o:p></p><p class=MsoNormal>Circle One: Totally Blind <o:p></o:p></p><p class=MsoNormal>Do you use a seeing eye dog? <o:p></o:p></p><p class=MsoNormal>Do you have special equipment or dietary needs: If so, what no no ? _______________________________________________________ <o:p></o:p></p><p class=MsoNormal>List any medical problems and or medications taken on a regular basis. (Use the back of this page or attach list) no <o:p></o:p></p><p class=MsoNormal>Emergency Contact: <o:p></o:p></p><p class=MsoNormal>Name Kim Rival ________________________________________________Phone 860 978 2411 _______________________________ <o:p></o:p></p><p class=MsoNormal>Please promptly return the completed application to Lion Bob Christensen, 275 Lower Lane, Berlin, CT 06037. <o:p></o:p></p><p class=MsoNormal>For more information please contact me at (860) 680-7227 or by e-mail at rachriste1@cs.com<o:p></o:p></p><p class=MsoNormal><o:p> </o:p></p></div></body></html>