*Required fields
*First Name
Middle Name
*Last Name
Age
Birthdate (MM/DD/YYYY)
*Parents E-mail
Mailing Address
City
State
Zip
Parents Phone Number (Home)
Parents Phone Number (Cell)
Parents Name
School:
School related extracurricular activities/ clubs/ sports/ organizations
Princess Sponsor(s), if applicable:
Miss Black Texas USA Delegate Mentor Choice (if applicable): Mentor Name
Mentor Title
T-shirt size Select One Small Medium Large Extra Large
How did you hear about this pageant? Select One Miss Black USA Website Facebook Recruiter Local Pageant Poster or Flyer Current Contestant Former Contestant Search Engine Other
Would you like to refer a friend? The Princess who refers the most friends will receive a $500 savings bond June 1,2010. Future Princess Name: Parents Names: Email Address: Phone Number:
I certify that my child will be between the ages of 5-10, by August 1, 2010 to be considered as a finalist to go to the national Miss Black USA Pageant in Washington D.C., August, 7-9 2010. If my child is between the ages of 3-4 is in the Princess "Tiny Tot" Club, then I know that my child will NOT be eligible to participate at the National Level unless she is 5 years old by August 1, 2010. I give the Miss Black USA Organization full rights to my childs picture and release them to use the picture at their discretion in affiliation with the Miss Black USA Organization and the Miss Black Texas USA Organization. I understand that if my child is uncooperative or consistently late or inappropriately dressed for activities or appearances she may be dismissed from the Miss Black USA and Miss Black Texas USA Princess Program.
*Print Name
*Date
*Print Signature
Note: Your online application will not be processed without payment of the $50.00 non-refundable application fee.
