United States
Polka Association
Junior & Teen Miss USPA Contestant Application
(Applicant, please print legibly and in blue or black ink)
Name: (Last)___________________________ (First)_____________________________
(Middle)_______________________________
Date of Birth: ___________________________
Current mailing address:___________________________________________________________________________
Guardian’s cell/home number:____________________________________________
Guardian’s E-mail:________________________________________________________
Guardian’s Names: (Last)___________________ (First)_________________________
(Last)___________________ (First)_________________________
Name of school currently enrolled:________________________________________
Activities: (list and clubs, school activities or organization to which you belong and any offices held. Please use back of page if necessary.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Name of Presenter/Dance Partner:________________________________________
Favorite Polka Band:______________________________________________________
Favorite Polka Song:______________________________________________________
Signatures:
I submit this application to the United States Polka Association and do solemnly swear that the contents of the application provided by me are true.
__________________________________________________/_____/_______
Contestant’s Signature Date
I do solemnly swear that the contents contained herein are true to the best of my knowledge. I also give the United States Polka Association permission to use all information submitted for publicity purposes.
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Guardian Signature Date