| Ms. Wheelchair Massachusetts Pageant Application & Information Ms. Wheelchair Massachusetts 2012 Pageant March 3rd 2012 |
This application and $75.00 Entry Fee are due by February 10th 2012, Please make your checks or money
orders payable to: “The Ms. Wheelchair Massachusetts Foundation” and send the completed application,
photo and Entry Fee to: Ms Wheelchair Massachusetts Foundation, PO Box 168, Raynham, MA 02767-0168.
For more information on the pageant please contact Autumn Grant at (774) 501-1185 or e-mail
mswheelchairmass06@yahoo.com
2012 PAGEANT REQUIREMENT DETAILS
Name: ____________________________________________________________________________________________
(Please print your name as you wish it to appear in the pageant program.)
Address: ___________________________________________________________________________________________
Zip Code: _______________
E-mail address: _____________________________________________________________
Home Phone: ( ) ________________________________________________________
Work Phone: ( ) ________________________________________________________
Marital Status: Single ______ Married _______ Divorced ______ Widowed _______
Are you a U.S. citizen? Yes __________ No____________ (you must be a U.S. citizen to compete)
How long have you lived at your current residence? ________ years ________ months
How long have you lived in the state of Massachusetts? _______ years ______ months
Date of birth: ___________________ Age at onset of disability: __________________
Primary Disability: __________________________________________________________________________________
__________________________________________________________________________________________________
Does your disability require you to perform your daily living activities from a wheelchair or scooter?
_________________Yes______________No
Describe limitations disability causes: ____________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe current medical condition and diagnosis and any secondary diagnosis: _________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Do you require personal assistance daily? ___________ Yes ___________No
Type of wheelchair: Power ____ Manual _____ Scooter * _________
*a mobility aid belonging to any class of three or four-wheeled vehicles, designed for and used by individuals with mobility
impairments
Width of wheelchair: ______________________
What percentage of time do you depend on your wheelchair for mobility? _______________%
Please describe your current method of vehicular transportation: __________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Will you require hotel accommodations to attend the pageant? __________Yes _________No * accommodations not included
in pageant fee
Please describe any special needs you would require during a hotel stay – i.e. shower chair, transfer board, etc.:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
__
Do you require any special dietary consideration? _______ Yes _______ No
If yes, please explain: ______________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
EDUCATION BACKGROUND:
High School: ________________________________________________________________ Years Attended: ____________
Diploma: _________ Yes ___________ No __________ GED
College/University: _______________________________________________________________________________________
Dates Attended: ______________ to _____________ Degree/Major: _____________________
Other: ______________________________________ Date Attended: ________ to _________
Diploma: ___________ Yes _____________No
EMPLOYMENT HISTORY: (If any)
(Use back of page if more space is needed.)
Current Occupation: ___________________________________________________________________________________
Employer: ____________________________________________________________________________________________
Address: _____________________________________________________________________________________________
_____________________________________________________________________________ Zip Code: ______________
Phone: ( ) _______________________
Current Job Duties: ____________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If you are chosen Ms. Wheelchair Massachusetts, can you get time off from your job or school to travel?
_____ Yes ______ No ______ Not Sure
If yes, how much time __________________________________________________________________________________
(How much do we want? We need a commitment of 1 activity/event a month. Can you do this?)
ACTIVITIES/ACHIEVEMENTS/SPECIAL INTERESTS:
Please describe your involvement in the following categories:
• Organization Memberships and Activities (include dates): __________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
• Awards, Achievements and Honors (include dates): _______________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_______________________________________________________________________________________________________
• Hobbies, Special Interest, Interesting Information: __________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
___
________________________________________________________________________________________________________
________________________________________________________________________________________________________
COMMUNICATION SKILLS:
On a scale from 1 to 10 (10 being excellent) how would you rate your communication skills?
• Public speaking experience (specific examples – please include dates): _________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
• List examples of your advocacy (please include dates): _____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
SELF PERCEPTION:
What five (5) words best describe you?
(1) _____________________________________________ (4) ___________________________________________
(2) ______________________________________________ (5) _________________________________
(3) ______________________________________________
PERSONAL MOTTO/SLOGAN:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
BIOGRAPHY:
Please write a brief biography about yourself as you would like to see it appear in the pageant program. Please limit your
biography to 75 words or less.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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HUMOROUS INCIDENT:
Please describe a humorous incident that has happened to you relating to or as a result of your disability.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
COMPANION INFORMATION:
Name of your companion: ___________________________________________________________________________
Relationship: ______________________________________________________________________________________
Address: __________________________________________________________________________________________
_____________________________________________________________________ Zip Code: ___________________
E-mail address: _____________________________________________________________________________________
Phone: ( ) ____________________________________
Does your companion require any special needs – i.e. food, mobility, etc. ? ______________________________________
__
___________________________________________________________________________________________________
____________________________________________________________________________________________________
IN CASE OF AN EMERGENCY:
Notify: ____________________________________________________________ Phone: ( ) _____________________
Mobile Number: ( ) _______________________________________________ E-mail: __________________________
PHYSICIAN’S NAME:
Name: __________________________________________________________ Phone: ( ) ________________________
Address: _____________________________________________________________________________________________
_____________________________________________________________________________ Zip Code: ________________
SPECIALIST’S NAME:
Name: __________________________________________________________ Phone: ( ) __________________________
Address: _______________________________________________________________________________________________
___________________________________________________________________________ Zip Code: __________________
SPONSOR/S INFORMATION:
• Name: __________________________________________________________________________________________
Company/Organization: __________________________________________________________________________________
Address: ______________________________________________________________________________________________
_________________________________________________________________________ Zip Code: ____________________
E-mail Address: ___________________________________________________________
• Name: __________________________________________________________________________________________
Company/Organization: __________________________________________________________________________________
Address: ______________________________________________________________________________________________
_________________________________________________________________________ Zip Code: ____________________
E-mail Address: ___________________________________________________________
• Name: ____________________________________________________________________________________________
Company/Organization: ___________________________________________________________________________________
Address: _______________________________________________________________________________________________
_______________________________________________________________________________ Zip Code: ______________
E-mail Address: _____________________________________________________
• Name: ____________________________________________________________________________________________
Company/Organization: ___________________________________________________________________________________
Address: _______________________________________________________________________________________________
________________________________________________________________________________ Zip Code: ______________
E-mail Address: __________________________________________________________________________________________
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RELEASE OF INFORMATION AND DISABILITY VERIFCATION
MS. WHEELCHAIR MASSACHUSETTS PAGEANT
I understand that the submission of this application does not entitle me to participate in the Ms. Wheelchair Massachusetts
Pageant. I understand that I will be notified of my participation by the Pageant Coordinator(s).*
I hereby certify that the information provided in this application is true and correct to the best of my knowledge, information and
belief. I hereby give my permission to the Ms. Wheelchair Massachusetts Pageant to use the information provided in this
application in their publications for the pageant and in any other publications regarding the pageant.
I give permission for photo, video and audio recording(s) of my participation in the Ms. Wheelchair Massachusetts Pageant. I
give permission to the Ms. Wheelchair Massachusetts Pageant to use these photos and recordings in future promotion of the
pageant.
I also understand that if I am selected as Ms. Wheelchair Massachusetts, I will compete in the Ms. Wheelchair America 2013 in
Providence Rhode Island August 6th - 12th 2012. I will be responsible for fundraising the cost of my entry fee (currently $1850 which
includes accommodations and food for myself and a companion) and my transportation costs to and from the event with the
help and guidance of the Ms Wheelchair Massachusetts Foundation.
By signing below I also certify that I am between the ages of 21 and 60, I am a US citizen, I have lived in the state of
Massachusetts for the last six months, I use a wheelchair for 100% of my daily mobility and that I have never held the title of
Ms. Wheelchair in a different state. If crowned Ms. Wheelchair Massachusetts you may be asked to provide verification of
disablility from a medical professional.
Name Printed
_______________________________________________________
Signature of Applicant
_______________________________________________________
Date: ________________________
(This release form must accompany the application.)
* Refunds will accompany 14 day advance notification of non-participation.
For additional information contact:
Autumn Grant
Phone: (774) 501-1185
E-mail: mswheelchairmass06@yahoo.com
Please note that an additional information packet with extra ticket and apparel order forms will be sent out as soon as
your application and entry fee are received. If you wish to send in extra ticket orders with you application please feel
free to do so. This application will automatically add you the MWMass Mailing List that will keep you updated on the
pageant. The information supplied in this application beyond the eligibility requirement verification of:
1. A U.S. and Massachusetts citizen between the ages of 21 & 60
2. Must utilize a wheelchair for 100% daily mobility
3. Marital status is not a consideration
Every effort will be made to accommodate and assist contestants in any way possible so that they can participate in this
great event!
*EVERYONE WHO MEETS THE REQUIREMENTS WILL BE CONSIDERED!*
* APPLY WITH CONFIDENCE!*
| Ms Wheelchair Massachusetts Foundation A Program of Achievement, Advocacy and Opportunity for Women with disAbilities in Massachusetts |
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| To request an application in MSWord or PDF format please email admin@mswheelchairmass.org |