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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link=blue vlink=purple><div class=WordSection1><p class=MsoNormal><img width=151 height=102 id="Picture_x0020_1" src="cid:image002.png@01CE20C1.DB9D5020"><a name="_GoBack"></a><span style='font-size:12.0pt'><o:p></o:p></span></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>5<sup>th</sup> Annual <o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>2013 Connecticut <u>SENIOR</u> VIP Fishing Tournament<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Date: Sunday, April 21, 2013<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>( See schedule for times)<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Tournament VIP Partic~ipant and Volunteer Application<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Sage Park Pond, Berlin Connecticut<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Instructions: Each VIP will be allow 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. Please complete and return this application BEFORE Saturday, April 6, 2013.<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>_____VIP _____ Sighted Guide _____ Volunteer<o:p></o:p></span></b></p><p class=MsoNoSpacing align=center style='text-align:center'><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>First Name____________________ Last Name_____________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Street_______________________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>PO Box_____________________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>City__________________________________State______Zip_________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Home Phone________________________Cell______________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Email Address:_______________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Date of Birth_________________Sex ____M____F<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Are you a Lion? _____YES _____ NO <o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>If YES, which club?___________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Do you have a preferred “companion” to assist you during the event? <o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>___ YES ___ NO<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Companion’s name:__________________________________________ <o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Please specify:<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>____Sighted ____Totally Blind ____Partially Sighted ____Newly Blind<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Do you use a wheelchair, walker or seeing eye dog? ___ YES ___ NO<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Do you have special equipment or dietary needs? ___ YES ____NO <o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>If so, please explain___________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>List any medical problems and/or medications taken on a regular basis ____________________________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>____________________________________________________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Name of Emergency Contact: _________________________________Phone:_____________________<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Please return this completed application to Lion Charley Satkowski <u>BEFORE</u> Saturday, April 6, 2013.<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Charley Satkowski<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>222 Toll Gate Road<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Berlin CT 06037-3610<o:p></o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNoSpacing><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>For additional information, or if you have questions, please contact Charley @ (860) 828-1427 or email </span></b><a href="mailto:satkowski@sbcglobal.net"><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>satkowski@sbcglobal.net</span></b></a><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p></o:p></span></b></p><div style='mso-element:para-border-div;border:none;border-bottom:solid #4F81BD 1.0pt;padding:0in 0in 4.0pt 0in'><p class=MsoTitleCxSpFirst><b><u><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p><span style='text-decoration:none'> </span></o:p></span></u></b></p><p class=MsoTitleCxSpMiddle><b><u><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:black'><o:p><span style='text-decoration:none'> </span></o:p></span></u></b></p><p class=MsoTitleCxSpMiddle><b><u><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:black'>SCHEDULE</span></u></b><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:black'>:<br>Registration and Breakfast (8:00am to 9:00am)<o:p></o:p></span></b></p><p class=MsoTitleCxSpMiddle><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:black'>Fishing (9:00am to 12:00 noon)<o:p></o:p></span></b></p><p class=MsoTitleCxSpLast><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:black'>Lunch (12:00 noon)<u><o:p></o:p></u></span></b></p></div><p class=MsoNormal><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNormal><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Directions to Sage Park:<o:p></o:p></span></b></p><p class=MsoNormal><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><br><u>Using 1-91 (North or South)<br></u>Take I-91 to Exit 22 North (Route 9)<br>Travel approximately 3 miles on Rt. 9 to Exit 22 off Rt. 9 and proceed to end of ramp. Turn right. Proceed 50 yds. to next light and turn right onto Worthington Ridge. Proceed straight through next light (center lane) on Worthinton Ridge. Continue to end of Worthington Ridge (approximatley 1-1/2 miles). At light at end of Worthington Ridge take left and go north on route 15 (Berlin Turnpike). Take right at sign for Sage Park.<br><br><u>Using I-84 (East for West)<br></u>Take I-84 to Rte 72 Exit for New Britain.<br>Continue on Route 72 East through New Britain. (Route 72 becomes Route 9 South). Take exit 22 off Route 9- proceed to end of ramp. Turn right. Proceed 50 yards to next light and turn right onto Worthington Ridge. Proceed straight through next light (center lane) on Worthington Ridge. Continue to end of Worthington Ridge (approximately 1-1/2 miles). At light at end of Worthington Ridge take left and go north on route 15 (Berlin Turnpike). Take right at sign for Sage Park.<br><br><u>Route 15 from Hartford:<br></u>Follow Route 15 and enter Berlin.<br>Pass Mickey Finns and continue for several miles.<br>Take left to northbound lane of Rte. 15 at third light after Mickey Finns. (intersection of Worthington Ridge with Rte. 15). (Fire house across street on left).<br>Go North on Rte. 15 for 1/4 mile and take right at sign for Sage Park.<br><br><o:p></o:p></span></b></p><p class=MsoNormal><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'><o:p> </o:p></span></b></p><p class=MsoNormal><b><u><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>Route 15 from New Haven:<br></span></u></b><b><span style='font-size:16.0pt;font-family:"Arial","sans-serif"'>At Meriden Rte. 91/15 intersection take Exit 17 to Berlin.<br>Follow Rte. 15 north into Berlin.<br>Pass fire station on right at light.<br>Continue on Rte. 15 for approximately 1/4 mile and take right at sign to Sage Park.<o:p></o:p></span></b></p><p class=MsoNormal><o:p> </o:p></p></div></body></html>