APPLICATION FOR
Great Lakes Ms Leather Pride 2017
Please print or type legibly. Complete this form thoroughly and concisely. Make a copy for your records. Several of your answers will be read on stage during the contest.
Name you will use for publication:
Full legal name:
Address:
City: State/Province:
Zip/Postal Code: Country:
Home Phone: ( ) Cell Phone: ( )
E-mail Address:
May we publish your name/contact info on a list for contestants, staff and judges only? Yes / No
Sponsored by (if applicable):
Sponsor(s) address:
Sponsor(s) Phone Number:( ) E-mail:
Age: Height: T-Shirt size: Favorite Color:
Favorite word(s):
Tattoos/Piercings/Other Body Modifications:
Occupation:
Current title(s):
Previous title(s) held:
Club/Bar Affiliation:
Hobbies/other interests:
How long you been involved in the leather, S/M, fetish lifestyle?
Community organizations and charities with which you have been involved (include phone number, contact person and the number of years involved.)
How have you integrated leather, S/M, fetish into the rest of your life and your relationships?
Why do you want to be Great Lakes Ms. Leather PrideTM?
If you become Great Lakes Ms. Leather PrideTM, how will you integrate the necessary commitments of the title with your other life responsibilities?
Write a 35-word personal ad describing what you would look for if you were looking for a date:
Fantasy: Contestants are required to perform a leather, S/M, fetish fantasy sequence. Please describe your fantasy briefly. Include a list of props and equipment you will be using as well as any assistance you may require. Please no nudity or live sex acts, no motorcycles, no power tools, no flames other than candles (limit- no more than 6) and no live animals on stage. You will have no more than 4 minutes on stage for your fantasy.
Music being used:
Will you be using any props that will leave a residue on stage or are pyrotechnic in nature? This includes scenes involving fire, wax, blood, etc. Please list below.
Please list any medical conditions and/or medications that our staff should be aware of:
Emergency Contact Name:
Phone Number: Home ( ) Cell ( )
Relationship:
Please write a 75 – 100 word biography for publication in our contest program book:
WAIVER
You must read, sign and date this waiver or your application will not be accepted.
I hereby waive any and all claims for injury or damage to my person, property, or reputation that may arise now or in the future from any cause whatsoever against the producers of Great Lakes Ms. Leather PrideTM to include Great Lakes Leather Alliance, its producers or volunteers, the venue, its owners, operators, employees, agents, lessors, lessees or any subsidiary thereof. Further, I release all claims to the use of my name, likeness or photograph, whether by still photographs, video recording, audio recording or any other medium authorized by the owner of Great Lakes Ms. Leather PrideTM. I understand that any application may be rejected for cause. I agree that if I am, indeed, the winner, that I will be required to sign an agreement regarding the responsibilities of the title. I also agree to make no commercial use of Great Lakes Ms. Leather PrideTM title without written permission from the owner of said title.
I certify that I am 21 years of age or older.
Print nameDate
Signature