Miss Contestant Information Form

Miss Candidate Information Form

Miss Great Lakes and Miss South Bend Scholarship Competition
Candidate's Name*

First NameLast Name
Candidate's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of time at this address*
Years and months
COUNTY of Residence*
YESNO
Candidate's Birthdate*

MonthDayYear
Candidate's Age **
See age guidelines below
Candidate's Cell Number*
YesNo
Candidate's E-mail Address*

Confirmation Emailmyname@example.com
*Age Guidelines

A candidate shall not be less than seventeen (17) years of age and a graduating high school senior on the date of the commencement of the Local Competition in which she competes, nor more than twenty-five (25) years of age on December 31st in the calendar year in which she will compete in the State Competition.

MAO Candidates:
- Must be at least eighteen (18) years of age as of July 31st in the calendar year of the State Competition in which she competes;
- Must be a high school graduate or equivalent by July 31st in the calendar year of the State Competition in which she competes; and
- Must not be older than twenty-five (25) years of age as of the last day in the calendar year of the State Competition in which she competes (December 31st)
- The year of the State Competition is 2022.
For the avoidance of doubt, a Candidate cannot turn twenty-six (26) years of age at any time during the calendar year in which she will compete at state.

For the avoidance of doubt, 13 to 17 year old high-school graduates, as well as 18 year old non-graduates as of July 31st, must compete at MAOTeen level.
YesNo
Grade level for 2021-2022*
School (if applicable)*
College Major (if known)*
Employer (if employed)*
Type N/A if unemployed
Date of Hire*

MonthDayYear
*Date and employer address only required if claiming eligibility based on employment
Employer Address (location of your workplace, not the home office; if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Father's Name*

First NameLast Name
Father's Cell Number*
Mother's Name*

First NameLast Name
Mother's Cell Number*
Parent's Primary E-mail Address*

Confirmation Emailmyname@example.com
YesNo
StepfatherStepmotherBoth Stepfather and Stepmother
Stepfather's Name*

First NameLast Name
Stepfather's Cell Number*
Stepmother's Name*

First NameLast Name
Stepmother's Cell Number *
YESNo
If YES, what is your title?*
If YES, when does your reign end?*
Social Impact Initiative Name*
Hobbies (list 2-3, will be read on stage)*
Tell us a Fun Fact about yourself (will be read on stage)*
Talent Performing (baton, dance, vocal, dance, instrumental, , gymnastics, etc.)*
YesNo
Title of Talent Music Track*
Mic, wirelessMic with standMic, lavalierePianoN/AOther
Please answer the following questions.

This information will not be shared with the judges and has no bearing on your scores, but helps the Miss Great Lakes and Miss South Bend programs with required reporting to the Miss America Organization.
Total Miss America Scholarship Fund monies raised in the last twelve (12) calendar months:*
Total CMN money raised in the last twelve (12) calendar months:*
Total CMN hours donated (in person or virtual) in the last twelve (12) calendar months:*
Total number of other community projects (in person or virtual) in the last twelve (12) calendar months: *
Other community service funds collected and donated in the last twelve (12) calendar months: *
Other community service hours (in person or virtual) performed in the last twelve (12) calendar months:*
MISS AMERICA SCHOLARSHIP (MAO) FUND FUNDRAISING:

By completing and submitting this form, the candidate understands that they must have the required $100.00 fundraising donation in their MAO Scholarship account by 9:00 p.m., August 27, 2021. If the required funds are not in their account by the deadline, they will not be qualified to compete at Miss Great Lakes / Miss South Bend 2022.
Should be Empty:

Miss Candidate Information Form