Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Name: Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature Executive Director: Executive Director’s Signature: Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)
Appears in 2 contracts
Samples: 2017 Local Contestant Contract, 2017 Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Competition Title _ until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Competition Title _ for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Title: Contestant Statement Type Contestant Name State Title: Type Competition Title Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant competition system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature State Executive Director: State Executive Director’s Signature: State Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local NameTitle: Type Local Title Platform: Full Name (as you wish it listed in Program Book): _ Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Phone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Type Organization Name Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)
Appears in 1 contract
Samples: 2018 State Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature Executive Director: Executive Director’s Signature: Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) INITIALS DATE Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Age: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)) Attachment B Medical Information Form INITIALS DATE Please use this form to provide any information referenced in Section 3.2. Local Name: Contestant’s Name: Date of Birth: Home Address: Who should be called in case of an emergency? Name: Address: Phone: Home: Cell: Medical Insurance Company / HMO Name: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other Family Physician: Physician’s Phone: Home: Office: Your Blood Type: Medications to which you have an allergic reaction: Any physical problems that could cause you discomfort (in reference to section 3.2.1 of the Contract) INITIALS DATE Attachment B Medical Information Form Any Food Allergies: Dental Insurance Company Name: Address: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s Address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other PLEASE ATTACH A COPY OF YOUR INSURANCE CARDS, INCLUDING MEDICAL, PRESCRIPTION AND DENTAL. I certify the policy(s) named above is now in force and will be maintained through December, 20 . I understand that contestants are responsible for all medical/dental expenses incurred during the time in which they participate in the Miss competition activities and that neither the Miss Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE* PARENT/GUARDIAN SIGNATURE AND DATE* Pre-Authorization for Medical Treatment Regarding Contestants below the Age of 18: I hereby authorize the Miss Organization physician, other appropriate health care provider and/or Miss Organization’s registered nurse to perform medical treatment deemed necessary for: (CONTESTANT NAME) PARENT/GUARDIAN SIGNATURE AND DATE *If the contestant is below the age of 18, the parent or guardian must sign the above Medical Responsibility and Authorization Information Form. In all other cases, either the contestant or her parent/guardian may sign. The completed form must be returned with the contestant contract. IN THE EVENT THAT YOU DO NOT HAVE MEDICAL AND/OR DENTAL INSURANCE I certify that I do not have medical and/or dental insurance coverage and I understand that contestants are fully responsible for any and all medical / dental expenses incurred during the time in which they participate in Miss Competition activities and that neither the Miss Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE*
Appears in 1 contract
Samples: Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type CompetitionMiss Chesapeake/Title Miss Xxxxxxxx Xxxx_x until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type CompetitionMiss Chesapeake/Title Miss Xxxxxxxx Xxxx_x for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Title: Contestant Statement Type Contestant Name Local Title: Miss Chesapeake/Miss Virginia Beach Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature State Executive Director: State Executive Director’s Signature: State Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Miss Chesapeake/Miss Virginia Beach Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: I confirm I will not be older than twenty-five (25) years old on December 31, 2018 Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Miss Chesapeake/Miss Virginia Beach Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)
Appears in 1 contract
Samples: 2018 Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: State Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature State Executive Director: State Executive Director’s Signature: State Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)
Appears in 1 contract
Samples: 2018 Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title Competition Name until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title Competition Name for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Type Contestant Name Local Title: Contestant Statement Type Contestant Competition Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature State Executive Director: State Executive Director’s Signature: State Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Type Competition Name Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: I confirm I will not be older than twenty-five (25) years old on December 31, 2018 Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Type Organization Name Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)) Attachment B Medical Information Form Page 1 Please use this form to provide any information referenced in Section 3.2. Local Name: Contestant’s Name: Type Competition Name Type Contestant Name Date of Birth: Home Address: Who should be called in case of an emergency? Name: Address: Phone: Home: Cell: Medical Insurance Company / HMO Name: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other Family Physician: Physician’s Phone: Home: Office: Your Blood Type: Medications to which you have an allergic reaction: Any physical problems that could cause you discomfort (in reference to section 3.2.1 of the Contract) INITIALS DATE Attachment B Medical Information Form Page 2 Any Food Allergies: Dental Insurance Company Name: Address: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s Address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other PLEASE ATTACH A COPY OF YOUR INSURANCE CARDS, INCLUDING MEDICAL, PRESCRIPTION AND DENTAL. I certify the policy(s) named above is now in force and will be maintained through December, 20 1_8. I understand that contestants are responsible for all medical/dental expenses incurred during the time in which they participate in the Miss _ Type Competition Name competition activities and that neither the Miss Type Organization Name Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE* PARENT/GUARDIAN SIGNATURE AND DATE* Pre-Authorization for Medical Treatment Regarding Contestants below the Age of 18: I hereby authorize the Miss Type Organization Name Organization physician, other appropriate health care provider and/or Miss Type Organization Name Organization’s registered nurse to perform medical treatment deemed necessary for: Type Contestant Name (CONTESTANT NAME) PARENT/GUARDIAN SIGNATURE AND DATE *If the contestant is below the age of 18, the parent or guardian must sign the above Medical Responsibility and Authorization Information Form. In all other cases, either the contestant or her parent/guardian may sign. The completed form must be returned with the contestant contract. IN THE EVENT THAT YOU DO NOT HAVE MEDICAL AND/OR DENTAL INSURANCE I certify that I do not have medical and/or dental insurance coverage and I understand that contestants are fully responsible for any and all medical / dental expenses incurred during the time in which they participate in Miss Type Competition Name Competition activities and that neither the Miss Type Organization Name Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE*
Appears in 1 contract
Samples: 2018 Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title Competition Name until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title Competition Name for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Type Contestant Name Local Title: Contestant Statement Type Contestant Competition Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature State Executive Director: State Executive Director’s Signature: State Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Type Competition Name Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Check Bo I confirm I will not be older than twenty-four (24) years old on December 31, 2018 Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 INITIALS DATE Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)) INITIALS DATE Attachment B Medical Information Form Please use this form to provide any information referenced in Section 3.2. Local Name: Contestant’s Name: Type Competition Name Type Contestant Name Date of Birth: Home Address: Who should be called in case of an emergency? Name: Address: Phone: Home: Cell: Medical Insurance Company / HMO Name: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other Family Physician: Physician’s Phone: Home: Office: Your Blood Type: Medications to which you have an allergic reaction: Any physical problems that could cause you discomfort (in reference to section 3.2.1 of the Contract) INITIALS DATE Attachment B Medical Information Form Page 2 Any Food Allergies: Dental Insurance Company Name: Address: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s Address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other PLEASE ATTACH A COPY OF YOUR INSURANCE CARDS, INCLUDING MEDICAL, PRESCRIPTION AND DENTAL. I certify the policy(s) named above is now in force and will be maintained through December, 20 . I understand that contestants are responsible for all medical/dental expenses incurred during the time in which they participate in the Miss Type Competition Name competition activities and that neither the Miss Type Organization Name Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE* PARENT/GUARDIAN SIGNATURE AND DATE*
Appears in 1 contract
Samples: 2018 Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of this Miss Type Competition/Title Alabama Local Preliminary until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of this Miss Type Competition/Title Alabama Local Preliminary for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Local Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Statement Contestant Name: Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with a any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition Pageant /Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature Local Executive Director: Local Executive Director’s Signature: Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3):
Appears in 1 contract
Samples: Alabama Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Name: Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature Executive Director: Executive Director’s Signature: Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 INITIALS DATE Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)) INITIALS DATE Attachment B Medical Information Form Please use this form to provide any information referenced in Section 3.2. Local Name: Contestant’s Name: Type Contestant Name Date of Birth: Home Address: Who should be called in case of an emergency? Name: Address: Phone: Home: Cell: Medical Insurance Company / HMO Name: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other Family Physician: Physician’s Phone: Home: Office: Your Blood Type: Medications to which you have an allergic reaction: Any physical problems that could cause you discomfort (in reference to section 3.2.1 of the Contract) INITIALS DATE Attachment B Medical Information Form Page 2 Any Food Allergies: Dental Insurance Company Name: Address: Employer or Company Name (If Group Plan): Policy Number: Name of Subscriber: Subscriber’s Address through December, 20 : Relationship of Subscriber to you: Self Parent/Guardian Other PLEASE ATTACH A COPY OF YOUR INSURANCE CARDS, INCLUDING MEDICAL, PRESCRIPTION AND DENTAL. I certify the policy(s) named above is now in force and will be maintained through December, 20 . I understand that contestants are responsible for all medical/dental expenses incurred during the time in which they participate in the Miss Type Competition/Title competition activities and that neither the Miss Type Organization Name Organization nor its medical insurance plan will be responsible for any such expenses. I certify that the above information is true and accurate. CONTESTANT SIGNATURE AND DATE* PARENT/GUARDIAN SIGNATURE AND DATE*
Appears in 1 contract
Samples: Local Contestant Contract
Other Competitions. If I win, I will continue to hold the title of Miss Type Competition/Title Xxxxxxx Xxxxx Community College until my successor is selected or appointed. I agree that, during my service in that role and until after the scheduled completion of the full term of the position of Miss Type Competition/Title Xxxxxxx Xxxxx Community College for which I was selected, I will not associate in any way with, promote, perform, judge or become a contestant or participant in any other regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I also represent that I am not a contestant, participant or titleholder in any other regional, national or international competition or local or state preliminary competition of a similar nature to the National Finals. This Other Competitions Form is to be completed, signed and approved by the State Executive Director. I understand that failure to observe and fully comply with the contestant contract, including but not limited to, Other Competitions, is a violation of this agreement. Contestant Name: Title: Contestant Statement Type Contestant Name Contestant Affirmation: I have read and understand the Other Competitions clause. I affirm that I do not hold a title with any other competition/pageant system and that I will not enter or associate in any way with, promote, perform judge or become a contestant or participant in any other program’s local, state, regional, national or international competition or preliminary competition of a similar nature to the National Finals, including but not limited to the National Sweetheart Pageant/Competition in Hoopeston, Illinois. I understand the consequences if I am not forthright in my disclosure statement. Contestant’s Signature: Contestant Signature Executive Director: Executive Director’s Signature: Executive Director Signature Date: Attachment A Supplemental Fact Sheet Page 1 Local Name: Platform: Full Name (as you wish it listed in Program Book): Full Name Phonetic Pronunciation: Date of Birth: Age: Home Telephone Number: ( ) Cell Phone Number: ( ) Email Address: College Information (if appropriate): Name of College/University: Year Graduated: College Major: Declared Minor: Scholastic Honors: (3) Scholastic Ambition: Career Ambition: Graduate School Information (if appropriate): Name of College/University: Degree Sought: Dates of Attendance: Current Status: Other Accomplishments: What type of talent will you present? (You need not give the exact title of your talent presentation. Merely indicate if you will dance (ballet, tap, etc.), sing (classical, popular, etc.), play a musical instrument (which one?), perform a comedy reading, dramatic skit, etc.) Attachment A Supplemental Fact Sheet Page 2 Special training in music, drama, dance, art: Father’s Name: Mother’s Name: Brothers and Sisters: Name: Name: Name: Age: Age: Age: Other interesting facts about yourself: The Miss Organization encourages the young women who participate in the Program to become involved in the community by supporting Children’s Miracle Network Hospitals. In addition to CMNH, if you choose to support a personal issue, what personal issue would you want to address during your Year of Service? Attachments (check here if included): ( ) Copy of Birth Certificate (Section 2.2) ( ) Copy of Driver’s License or Government Issued Identification Card (Section 2.2 & 2.3.1) ( ) Proof of Residence (Section 2.3.1) ( ) Official College Transcript (Section 2.3.2.1) ( ) Official Transcript of College Registration for Current Classes (Section 2.3.2.2) ( ) Copy of College Degree (Section 2.3.2.3) ( ) Official Graduate School Transcript (Section 2.3.2.4) ( ) Official Transcript of Graduate School Registration for Current Classes (Section 2.3.2.5) ( ) Copy of Graduate School Degree (Section 2.3.2.6) ( ) Employer W-2 Form (Section 2.3.3) ( ) Income Tax Filing (Section 2.3.3)
Appears in 1 contract
Samples: 2017 Local Contestant Contract