Entry Form
Official Henry/Des Moines County Entry Form
(EMAIL or MAIL ENTRY FORM & HEAD SHOT TO LOCAL ED)
Check your division: (Age as of JUNE 1 of State competition Year)
___Tiny Miss (local only): Ages 3-5 ___Lil' Miss: Ages 6-9
____Jr Miss: Ages 10-12 ___Outstanding Teen: Ages 13-17
___Miss Division: Ages 19-24
Name: ____________________________________________________________
Age as of June 1st of State Competition Year: ______ Date Of Birth:_________
Address: ___________________________________Apartment Number: _______
City: _______________________State: ___________ ZIP:_____________________
Home Phone: ( ) _______________________E-mail:_________________________
Mother’s Name: ____________________________________ Phone__________________
Father’s Name:_____________________________________ Phone ___________________
Name of School: ________________________________ Grade in School: __________
School and Community Activities, Honors and Awards:___________________________
_____________________________________________________________________
_____________________________________________________________________
Hobbies: ______________________________________________________________
_____________________________________________________________________
Other Interests: _________________________________________________________
_____________________________________________________________________
Ambition: _____________________________________________________________
Parents of prospective finalists must read the rules and following information, and sign below if the official application is to be considered.
Referred by:__________________________
________________________ ____________________________________
Signed: Student / Date Signed: Parent or Legal Guardian / Date
Jeff & Tina Shelledy- Executive Director
1616 West Mt Pleasant Street
West Burlington, Iowa 52655
Phone:319-759-3229
email:greatriverpageantsystems@yahoo.com
www.greatriverpageantsystems.com