EmailMe Form - Queens for a Cure 2012 Registration

Contestant Name *

Parents Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Email *

Phone Number *

### - ### - ####

Birth Date *

Age on November 5, 2011

Age Division

Referred By

I plan to raise a minimum $100 additional donation for the Race for the Cure *

Yes

No

Hair Color

Eye Color

Favorite TV Show / Movie

Favorite Book

Ambition

Queens for a Cure Registration
Includes Mandatory Events and One Chaperone Badge
$50 per person

$ Dollars . Cents

Mini Optionals

Mini Optionals
$5 each or $25 for all (See above)

$ Dollars . Cents

COVER MODEL
All contestants names will be printed in the program book. If you would like your contestants photo printed in the book, the fee is $10. Photos must be received by October 29th and must be emailed to queensforacure@comcast.net. BONUS - all photo submissions will be judged by a separate panel of judges and the highest scoring photo will be printed on the back cover of the program book! The winner will also receive a banner and crown from Queens for a Cure and the title of COVER MODEL!
$10 for the FIRST photo
$5 each additional Photo

$ Dollars . Cents

PERFECTLY PINK MODEL
It's all about pink! Submit any photo that features the color PINK to be considered for this contest! Photos must be received by October 29th and must be emailed to queensforacure@comcast.net. BONUS - all photo submissions will be judged by a separate panel of judges and the highest scoring photo will be printed on the back cover of the program book! The winner will also receive a banner and crown from Queens for a Cure and the title of PERFECTLY PINK!
$10 for the FIRST photo
$5 each additional Photo

$ Dollars . Cents

TALENT
Only the FIRST 15 talents registered and paid for will be eligible to compete. The cost to enter is $50. You must be entered in the main competition to be eligible to compete in the talent competition. We will award 1 Overall Talent Winner and 4 runners up out of all entries. The winner will receive a satin embroidered banner, exclusive QFAC pink ribbon crown and will join the 2012 royalty at all events including the photo shoot!

$ Dollars . Cents

Roses - Presented on Stage during Parade of Formal Wear
$5 for Single rose
$10 for Bouquet of Three Roses

$ Dollars . Cents

Child Admission
$3 ages 3-12 years

$ Dollars . Cents

Adult Admission
$5 ages 13+

$ Dollars . Cents

I have read and agree to the Terms of Service *

Yes, I agree.