Name:      Date:

Address:

City: State: Zip:

Permanent Address:

City: State: Zip:

Day Phone:    Evening Phone:

E-mail:

Date of Birth:   Age:

Parents Names:

Parents Contact Information:

What Type of Talent Will You Present: (1:30-2 min)

Special Training In Music, Drama, Dancing, Art, Etc:

 School and Grade:

GPA:   (You will need to provide a copy of your last report card.)

What Community Service Have You Been Involved In:

What Are Your Other Accomplishments? Are you a member of any civic groups or church/religious groups, school clubs?

Write a short essay of 150 words on why you want to be Miss Tri-Cities Outstanding Teen . (Please paste your essay in the field below)

By submitting this form, you certify that all of the above information is true and correct to the best of your knowledge.

You must have your Parents or Guardians permission to participate in the Miss Tri-Cities Outstanding Teen Program.