Miss Lewis County Scholarship Program

Contestant Entry Form

Name: ___________________________________ 

Age:  _____________________

Address: ____________________________________________________________

City, State, Zip: __________________________   

Phone: _____________________

Cell Phone: _______________________________

Email: _____________________

School attending: __________________________

Year in School _______________

Parent or Guardian Name: _______________________________________________

Address: _____________________________________________________________

City, State, Zip: ____________________________

Phone: _____________________

Talent that you might do for competition:

_____________________________________________________________________

Special training you have had for this talent:

_____________________________________________________________________

_____________________________________________________________________

Do you work? ______ 

If yes, place of employment ___________________________

Application Deadline: Friday, December 1, 2006

Send application to:

Miss Lewis County Scholarship Program

P O Box 431

Centralia, WA 98531