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APPEARANCE FORM

Form #4
Personal Health Form

The contents of this form are confidential.


Your Name:
Email:
Your Title
Pageant you are attending Mrs. Globe Ms. U.S. MISS U.S.
Contact person in case of emergency
Relation to you
Phone number of Emergency Contact
Are you a Vegetarian Yes No

Are there any foods that you are allergic to, or canot eat because of religious or gross out purposes:

 
Are there any medications are you are allergic to
Do you have any handicaps or impairments that we need to prepare for or be sensitive to?
Are you a Smoker Yes No
Do you have low blood sugar Yes No
Please note that it is your responsibility to maintain your sugar glucose levels at the pageant. If you have more than one "crash", we reserve the right to dismiss you from the pageant. Please check to confirm you understand this.

Do you have any medical history we need to be aware of?

 

If you are on any special medicine, please check the appropriate box.

 

 I understand that any medicine I need, I agree to bring myself. The pageant is not responsible for providing it.
I am not on any special medicine.
Mrs. Globe does its best to provide balanced meals. If you have special needs, it is your responsibility to provide these needs on your own and at your own expense. Check here to confirm you understand this.

I agree to all of the above items.



 

If you experience any difficulty with this system, please email us directly your information here

Continue to Form #5