IPAC Parent Form
Parents, return by March 1, 2017 for Meeting one and March 15 for Meeting two. Please email to or print and bring to the registration meeting March 1 or March 15.
March 1 and march 15 - Registration 6 PM.
Inspiration Meeting from 6:30 - 8:45 PM.
IPAC APPLICATION
Pageant location:
Martin Luther King Recreation Center
2922 Martin Luther King Jr Blvd (Entrance on Pennsylvania Avenue)
Dallas, TX 75215
PH: 972-421-8858
Email:
Facebook IPAC
Each parent or guardian must submit this form.
Parent's First Name: ______
Parent's Last Name: ______
Parent's Address: ______
Parent's City: ______
Parent's State/Province: ______
Parent's Zip code: ______
Parent's Email: ______
Parent's Work Phone: ______
Parent's Home Phone: ______
Parents's Cell Phone: ______
Additional phone: ______
Fax: ______
*Emergency contact person: ______
*EmergencyContactPhone: ______
Applicant's Information: ______
*Applicant’s First name: ______
*Applicant's Last Name: ______
Applicant's Address: ______
Applicant's City: ______
Applicant's State/Province: ______
Applicant's Zip code: ______
Applicant's Email: ______
Applicant's Phone: ______
Applicant's E-mail: ______
Applicant's Age: ______
Applicant's Birth Date: ______
***Please email a picture of the contestant to
*Applicant Height: ______
Weight: ______
Dress Size: ______
*Health: Circle One
Excellent Good Fair
*Any serious illness or disease: Circle One
Yes No
If yes, please explain: ______
Education
Name of School: ______
Address of School: ______
Telephone number of School: ______
Current Grade Level: ______
Other Schooling: ______
School Activities: ______
Extracurricular Activities: ______
Hobbies: ______
Have you participated in a pageant before?
Yes______No______
If yes, which one/s? ______
Payment $50 Paid by Family______
Payment $50 Paid by Sponsor Name: ______
Sponsor Business Name: ______
Sponsor Phone: ______
PLEASE SUBMIT THE APPLICANT'S AGREEMENT AND MEDIA RELEASE. SUBMIT THE APPLICATION FEE IN ORDER TO CONFIRM YOUR PARTICIPATION IN THE PAGEANT.
I have read and agree with the Terms And Conditions
YES______NO______
*Applicant's Name: ______
*Applicant's Age: ______
Parent or Guardian’s Name submitting release and agreement on behalf of applicant:
*Person's name accepting the terms of this agreement :
______
Relation to pageant participant: ______
*Terms and conditions of agreement:
Attention: please read the agreement before you agree to its terms. This is a legal and binding agreement .
To: Dr. Pamela Hardy, Founder, Pageant Director
Image 1 Enterprises, Inc., P.O. Box 261005, Plano, TX 75026-1005
I have volunteered to participate in IPAC without compensation to me or my parents.
No one in my family is an IPAC employee. I understand that if any of the following representations are false, or if I fail to abide by this agreement, I may forfeit my appearance in the IPAC pageant and all media events.
1. I am between the ages of 8 and 17. This release is submitted by my parent or guardian and agreed to release a photograph of the contestant on Facebook.
2. In the event I am a contestant in IPAC and / or Media Events, I do not have nor does any member of my family have any association with, nor am I friend or close acquaintance of any members of the following groups: (a)The IPAC producers, staff, employees, or any production personnel; (b)The known sponsors of the program or their advertising agencies; (c)Any TV station, network, or on-line network broadcasting the program of any corporate sponsor; (d)any corporate entity of which such station or network is a parent subsidiary or division and any employees of the foregoing persons, firms or agents thereof supplying prizes to the program; or, e) Any local, national, preliminary or final judge of IPAC or any Media Events.
3. I and my parents will not participate in any illegal, dishonest or deceptive act with respect to Image 1 Enterprises, Inc. and IPAC.
4. I also agree to adhere to all rules and regulations, cooperate with all requirements deemed necessary by you and follow all directions regarding my participation in IPAC.
5. The IPAC and others authorized by Image 1 Enterprises, Inc. shall have unlimited rights to all photographs and world wide media, along with everything associated with IPAC. All IPAC photographs, tapes and recordings will be owned by Image 1 Enterprises, Inc. and can be used for promotion at any time. Permission for use of IPAC photographs, tapes and recordings must be received from Image 1 Enterprises, Inc.
6. IPAC and others authorized by IPAC may use my name, photographs, recordings and biographical Information for advertising and publicizing the pageant. If appearances are needed, I will cooperate by making myself reasonably available and furnishing any material that is needed or requested.
7. I also agree that any and all prizes and won by me cannot be transferred, exchanged or redeemed and can only be used by me at such times as specified by IPAC and IPAC sponsors.
8. I understand that "you" in this agreement is a reference to the contestant and parent or guardian named on this application.
9. I release Image 1 Enterprises, Inc, IPAC and others connected with the program and organization including sponsors, from any claims arising out of injury or damage to me or my family in any way resulting from my participation in IPAC. I hereby Indemnify you and all those described above and hold you and them harmless from all liability, claims, actions, damages, expenses and losses of any nature whatsoever caused by or arising out of any statement, actions or perceived action I might make in or in connection with my participation in IPAC. This applies to applicants parents or guardian, family members and friends.
10. I acknowledge that nothing within this agreement may be amended, except in writing and signed by participant and IPAC.
11. I certify that all of the statements contained herein are true to the best of my knowledge and belief.
APPLICANTS’ AGREEMENT
I certify to IPAC that I am between the ages of 8 and 17, or, I will become 8 - 17 prior to the IPAC event. I certify that my age will not exceed 17 years old, I am single, have never been married, am not pregnant, nor have I had a marriage annulled, nor have I been divorced and I have not conceived a child.
I certify that I am of good moral character. I have been a resident of this City, state or nation for a period of six months prior to the date of the pageant in which I am applying to compete.
I certify that I am in good health. I understand that any personal appearance I might be asked to make, there may not be monetary gifts associated with my appearances.
I understand that when I agree with all the stipulations of The IPAC stated herein and submit this agreement and release to Image 1 Enterprises, my parent or legal guardian agrees and submits the same.
I am contracted and committed to abide by all rules and regulations of The Inspire Pageant and Awards Celebration.
I certify that I have read, understand and meet all the requirements as listed above and have made all true statements in this agreement and release.
I release Image 1 Enterprises, Inc., IPAC, MLK Rec Center, all employees and all others connected with the organization or program from any and all claims arising out of injury, promises, commitments, or any type of damage to me in any way that may result from my participating on the local or national level of the Pageant.
I hereby agree to indemnify any and all associates or sponsors and to hold it and all others connected with the organization or program, harmless from all liabilities, claims, actions, damages, expenses and losses of an kind or nature whatsoever caused by or arising out of or in connection with my participation on any level. This applies to applicants parents or guardian, family members and friends.
I understand that this agreement is between me, Image 1 Enterprises, Inc., and IPAC. I understand that there will be no refund of any pageant application fees for any reason.
Dr. Pamela Hardy
972-421-8858
PO BOX 261005
Plano, TX 75026-1005