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: ____________________________________


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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!*