Date of Birth:
Main Phone Number:
Home Phone Number:
Mobile Phone Number:
Work Phone Number:
Number of Children:
Number of Grandchildren:
Number of Great Grandchildren:
Volunteer Work/Special Interests:
Description of Talent Presentation
(Will you dance, sing, deliver monologue, etc.?) Please specify talent you will be sharing: *NOTE: Changes to Talent less than 7 days before the Pageant Cannot be accepted.
(Performance must not exceed 2 minutes and 45 seconds):
(If "Yes," the CD must be of good quality and have ONLY music necessary for your performance on the CD. Please bring backup CD for audio technician):
*There can be NO vocal tracks (your own voice or others) on your CD. For dancers, there can be no taps on your CD.
(title of song):
*If using a live accompanist, that person cannot be on the stage.
Composer and/or title of Broadway Show, opera, etc. from which the music originated
(check one box):
*Contestants are welcome to include props in their talent segment. However, all stage props must be relevant to the talent you are performing. All contestants are to provide their own props.
(Please let us know if you need tables for display of artwork, chairs to be used during talent, etc.):
Philosophy of Life
(35-second on stage presentation):
Region of Pageant you are entering:
Will you have a Sponsor?
(Contestants are welcome to seek a sponsor if they wish, but this is not mandatory. The Sponsor, should they desire, could agree to pay your entry fee and/or make a general donation to the Ms. Senior California of America Pageant Program):
Sponsor Business/Organization Name
Release of Personal Information Contestant:
I do hereby authorize Ms. Senior CA of America, Inc., Senior America, Inc., Ms. Senior CA Director, and CA Preliminary Pageant Directors, to disclose any information furnished by me on the Ms. Senior CA of America, Inc. Pageant(s) and Senior America, Inc., events/programs, including photos taken by Ms. Senior CA of America, Inc. and Senior America Inc., pageant photographers, video footage, for publicity purposes before, during and after the Pageant(s).
I understand this application will be reviewed by judges of the Ms. Senior California of America Preliminary Pageants, and (if you are a finalist in a Preliminary Pageant) the judges of the Ms. Senior California of America, Inc. State Pageant.
(Print your full name to sign your electronic consent to the Release of Personal Information, Liability and Financial Disclosure):