Ms. Wheelchair Massachusetts
Pageant Application & Information

Ms. Wheelchair Massachusetts 2011 Pageant

November 7th 2010


This application and  $150.00 Entry Fee are due by October 21st 2010, a discounted early fee of $125 is  
available for applications and entry fees received before September  15th 2010. 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


2011 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.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


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 2012
location TBA during the summer of 2011 I will be responsible for fundraising the cost of my entry fee (currently $1500 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
To request an application in MSWord
or PDF format please email
admin@mswheelchairmass.org