Miss Route 66 Pageant
___________
NUMBER								 Division ___________________
 
 Type or Print Neatly		                            e-mail address ___________________________________
 
   Name ____________________________________________________________     Telephone ______________________
 
   Address _______________________________     Town _______________________     State  _____     Zip ___________
 
   Age __________     Birth Date ______________      Place ___________________________________________________  
 
   Mother’s Name _________________________      Father’s/ Husband’s Name _______________________________
 
   Number of Brothers _________      Sisters _________    Children ____________   Grandchildren ______________  
 
   Grade  _____      Career _______________________________      Employer ___________________________________
 
   Hair Color _______________      Eye Color ______________      Best Asset ___________________________________
 
   One word that best describes you ____________________________________________________________________
 
   Hobbies/Interests/Talents ____________________________________________________________________________
 
_______________________________________________________________________________________________________
 
_______________________________________________________________________________________________________
 
    Ambition/Goal _______________________________________________________________________________________
 
_______________________________________________________________________________________________________
 
_______________________________________________________________________________________________________
 
  Favorite place or event on Route 66  _________________________________________________________________
 
  Because _____________________________________________________________________________________________
 
_______________________________________________________________________________________________________
 
   Sponsor(s) __________________________________________________________________________________________
 
_______________________________________________________________________________________________________

(Please fill out areas that apply.  Portions of ENTRY FORM will be read while contestant is on stage)  
 
GET ENTRIES IN EARLY – DISCOUNT ONLY AVAILABLE IF ENTRY PAID BY PRIOR MONTH
Only 15 entries accepted in each division
 
Make checks payable to:  IMPERIAL IMAGE
No checks accepted on pageant day ~ CASH ONLY

Mail application to:  PAGEANT ~ P.O. Box 345   ~ Newberry Springs, CA  92365

ENTRY FEE  -  $100.00
$125.00 if entry is received or postmarked after 8/31/09
(check division entering)
 
PETITE  (up to 2 years) ________     TINY (3 & 4 years)  _________
LITTLE (5 & 6 years) ________           PIXIE (7 & 8 years)  ________
JUNIOR (9 & 10) _________        PRE-TEEN (11 & 12)  ________
JR. TEEN (13 & 14 ) ________    TEEN  (15 - 17, single)   _______
MISS (18 - 24, single)  _______    MRS. (Married up to 50)  _______
MS. (single with child or over 24, divorced, widowed)  ________
CLASSIC (50 years and up)________

COSTUME OPTIONAL ($20.00)    ____________________
PHOTOGENIC OPTIONAL ($20.00)   ________________
TALENT OPTIONAL ($30.00)    _______________________
MINI-OPTIONALS ($30.00)   __________________________
TALENT ONLY ($60.00)   ______________________________

AMOUNT ENCLOSED            $ _______________

(Entry fee must be paid in full  by 8/31/09 to receive $100.00 entry)
 
FIRST IN LAST OUT: The sooner you  get your entry in with a minimum deposit of $25.00, chances are that you will be the last one out on stage; last one in division to enter is first out on stage.
 
REFUND POLICY: You are free to withdraw from the pageant at any time. But under no circumstances, for any reason, will you be entitled to a refund of any fee, full or in part, that you or someone else has paid on your behalf. Absolutely no exceptions to this policy.  Emergency circumstances will allowed any paid entry to be applied to State or following years pageant, if notification is received prior to listed registration time.
 
CHECK POLICY: You are responsible for all checks written on your behalf, to be written in good faith.  Should a check come back for any reason, a $20.00 fee per check is required in addition to the cash value of the check.  You are responsible for this.
No checks will be accepted after 8/31/09
 
CASH  ONLY  ON  PAGEANT  DAY
 
ACKNOWLEDGEMENT / PARENTAL CONSENT
I hereby certify that I have read and understand the refund & check policy. I agree to hold harmless the Route 66 Pageant, the Ramada Inn or any person, group or agency affiliated directly or indirectly with it, for any injury, loss or accident in connection with pageant activities.  I further permit any photos or videos of contestant to be used for publicity purposes.  My signature below an that of my parent or guardian (if necessary)  shall constitute this form to be a binding agreement and legal contract.

 
__________________________________________________	________________
Print Name						Date
 
______________________________________________________________________
Signature 
 
_____________________________________________________________________
Parent / Guardian Signature  (If under 18 yrs. Old)
 
MUST BE SIGNED