America's Yankee Miss Application

Contestant Full Name

Age at time of this pageant

Select Division

Birthday

Month

Day

Year

Cell phone

Home phone

COMPLETE Mailing Address

Where did you hear about this pageant?

Parent Name(s) if minor

Hobbies & Special Interests

Ambition for Future

SPONSOR'S NAMES - if any (will be mentioned during pageant and printed in program book)

SPONSORS are businesses or individuals who can pay your entry fees. This may be parents, friends or businesses. Remember that you can sponsor yourself if you wish!!! Up to 5 sponsors names will be announced during the pageant. This is a tax deduction for any business.

SPONSER ENTRY FEES:

Pageant Fee for all ages - $195.00

Registration Form with at least with $75.00 Deposit MUST BE RECEIVED IN PAGEANT OFFICE BY 2 Weeks Prior to event

NOTE: If received after deadline, a $25.00 Late Fee may apply

PayPal Accepted: CoutoPageants@aol.com

OR MAIL A CHECK TO: Couto Pageant Productions

P.O. BOX 65, SHELTON, CT 06484

NOTE: You do not NEED TO COMPETE in ANY OPTIONAL COMPETITIONS in order to WIN Pageant or High-Point Titles. Please select your Optionals:

Photogenic - $40 each

Modeling - $50 each

Outfit of Choice - $55 each

Talent - $60 each

If participating in talent, please indicate the talent type, length of time, and song title:

Plese email talent music to: sdsproductions@yahoo.com by the Thursday before the pageant. Put contestant's NAME and TALENT in the email memo.

PLEASE ENTER YOUR TOTAL AMOUNT DUE INCLUDING PAGEANT FEE

TOTAL ENCLOSED TODAY

Contestant Signature & Date

I/We hereby have read and understand all the RULES & REGULATIONS set forth by the pageant and release the Directors and Staff from any and all claims for damages or for injuries we may sustain while participating in any of the pageant activities. I/We give Couto Pageant Productions, Inc. permission to use any photos or video portion of the pageant weekend for advertisement.

I/We affirm that all information on this form is true & correct

(Parents must sign - if contestant is under 18 years of age)