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 Information
Name
First Last
Age
Parish of Residence
Address
Street Address City State ZIP Code
Contact Person Information
Name
First Last
Address (if different)
Street Address City ZIP Code
Home Phone
Cell Phone
Email
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*
MM slash DD slash YYYY
Name of Applicant*
Digital Online Signature approval*
- Yes: Digital Online Signature
I 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.

2019 Beneficiary Nomination

2019 Beneficiary Nomination

Applicant Information

Contact Person Information

985-320-4879

riffridgelcrawfishcookoff@gmail.com