2019 Beneficiary Nomination The Riff Ridgel Crawfish CookOff Benefit is a non-profit 501(c)3 organization dedicated to providing support to families and individuals in the local community whose lives have been impacted by a catastrophic illness or accident. Please provide the following information regarding the applicant and contact person if other than applicant. Be sure to print clearly. As a beneficiary of the Riff Ridgel Crawfish CookOff Benefit, you are agreeing to provide information as requested by the Board of Directors, including photographs, which may be used to advertise the event. Submission of this form does not confirm engagement. Applicant InformationName First Last AgeParish of ResidenceAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person InformationName First Last Address (if different) Street Address City ZIP Code Home PhoneCell PhoneEmail Please provide information regarding the applicant, type of accident/illness, age at time of accident/illness, extent of disability, etc.If the Riff Ridgel Crawfish CookOff Benefit Board of Directors is able to provide support to applicant, what is the most urgent need and approximate cost.Date* Name of Applicant*Digital Online Signature approval*Yes: Digital Online SignatureI understand that by clicking this radio button, the entered Name of Applicant will serve as his/her signature and will serve any and authorize the information on this form.