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Ms. and Junior Miss Wheelchair Maryland Application

Contestants must meet the following criteria:

A Maryland Resident between the ages of 21 and 60*
Utilize a wheelchair for 100% daily community mobility
Marital status is not a factor

*or between ages 14-20 for Junior Miss

Please fill out this questionnaire and return it along with the $300.00 application fee, a brief bio and photograph for our program book (professional photographs preferred). Photographs cannot be returned.

Contact Information

Name:
Address:
City:	State:	Zip:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Email:

Emergency Contact

Name:
Address:
City:	State:	Zip:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Email:
Relationship:

Personal Information

Age:	Date of Birth:	(mm/dd/yyyy)
Occupation:
Marital Status:	Number of Children:
Children's Names and Ages:
Spouse or Significant Other:
Hobbies:
What form of transportation do you use most often?
drive self public transportation other
If "other", please explain:

Medical Information

Briefly describe your disability:
What type of wheelchair do you use?
Do you take any medications?	Yes No
If yes, list names and dosing instructions:
Do you have any food or other allergies of which we need to be aware? Yes No
If yes, please explain:
Please note, some individuals may have service animals. Pease indicate if you are allergic to dogs or other animals.
Do you have a service animal?	Yes No

Additional Information

Sponsor(s): (please list company name, contact person, address, phone number, email address, and website.

List any awards/honors you have received, include diplomas, degrees, certifications, etc.

Community involvement/advocacy experience (memberships, offices held, public speaking, etc.) NOTE: These do not have to relate to disability.

Platform:

**You will be asked to give a three minute speech outlining your platform, its significance to you and the disability community, and what audiences you would target.**

What 5 words describe you best?

Please make sure your application accurately and honestly conveys what you most want our judges to know about you prior to submitting.

By clicking submit you certify that you are a Maryland resident between the ages of 21 and 60, or between the ages of 14 and 20 if you are applying for Junior Miss, and that you use a wheelchair for 100% daily community mobility.

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