| Ms. Wheelchair Massachusetts Pageant Application & Information Ms. Wheelchair Massachusetts 2009 Pageant |
*This Application and half of the $150 Application Fee ($75), accompanied by a photo are due by March 1st
2009. The balance of the Application Fee is due by March 15th, 2009. Please make your checks or money
orders out to: The Ms. Wheelchair Massachusetts Program and send the completed application, photo and
Entry Fee to: P.O. Box 168, Raynham, MA 02767-0168. Please contact Autumn Grant at (774) 501-1185 or e-
mail mswheelchairmass06@yahoo.com * For more information on the pageant please visit the:
2009 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 _____ 3-Wheeler (Amigo, Lark, etc.) _________
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.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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: ____________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------
RELEASE OF INFORMATION FORM
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 2010
pageant during the summer of 2009 the location TBD. I will be responsible for assisting the Ms. Wheelchair Massachusetts
Foundation in fundraising the cost of my entry fee (currently $1500 which includes hotel and meals for the titleholder and one
companion) and my transportation costs to and from the event.
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, community 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!*