Delegate Application Form

Full Name*

First NameMiddle NameLast Name

Are you competing for Miss or Teen?

MissTeen

Local Competition Title you are competing for

Miss Moline or Miss Blackhawk Valley

Birth Date

Date

Age

Delegate's E-mail

example@example.com

Delegate's Phone Number*

Delegate's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent(s) Name(s)

Parent(s) Phone Number(s)

Parent(s) Email

School or College/University

Student Status/Grade

Freshman, Sophomore, Junior, Senior, Graduate, etc.

Major/ Minor/ What are you studying?

Year Graduated if applicable and Major/Minor/Degree obtained

Current job or career

Scholastic Ambition

Career Ambition

Are you claiming eligibility to compete via residence, work, or school?

ResidenceWorkSchool

Please further explain your eligibility based on your answer to the above question

**See contract for detailed eligibility information pgs. 4-5

Talent (type & name of song, if using)

Talent Introduction (used for stage production)

Ex: She's been singing since the age of 5, here is "blank blank" performing her rendition to "blank."

Community Service Initiative title and brief information regarding the initiative

This brief information regarding your CSI here will help us when we put together the competition script.

Have you competed in the Miss America Opportunity before?

YesNo

If yes, when and at what level?

Do you have any relatives who have served as a volunteer, judge, or other official with the Miss America Organization?

YesNo

If yes, please list the relation, position, and last date they were involved with MAO

I confirm to the following:

I am a US CitizenI am femaleI qualify, to the best of my knowledge, based on eligibility requirements for the open vs closed titleI verify I meet the age requirements for the Teen/ Miss titleI am singleI do NOT have any dependents

Have you registered to compete through Miss America's bypass page and paid your annual $39.99 fee? This is mandatory in order to compete for both Miss and Teen.

YesNo

I understand I am required to raise a minimum of $30 for the American Heart Association via Spot Fund per Miss America rules and have successfully registered for a Spot Fund Account.

YesNo

I understand the Miss Blackhawk Valley Organization has a $100 fee in order to compete for both Miss and Teen titles.

YesNo

Signature

AGE REQUIREMENTS:

Miss America 18-28 – must be 18 by state competition, and no older than 27 at state competition
Miss America’s Teen 14-17 – must be 14 by state competition and no older than 18 at state competition.

*18 year olds have a PIVOT year, meaning they may decide to compete as a Teen OR a Miss

- Once you submit the application, your eligibility will be reviewed by our Board of Directors to ensure you are able to compete.

- Registering with MAO/paying your annual $39.99 fee is required before you are eligible to compete.

CLICK HERE TO REGISTER AND PAY $39.99 FEE

- Each delegate will also pay a $100 entry fee to Miss Blackhawk Valley in order to compete. This may be paid in cash or check day of the competition. Checks will be made payable to the Miss Blackhawk Valley Scholarship Program.

Please see "Prep Information Guide" document for additional paperwork requirements and details on the competition.

Miss and Teen Delegate Application: