Please answer each question thoroughly. Detailed responses allow the preliminary judges an opportunity to better get to know your pageant’s winner. Take time to include stories the resident has told you about her life and let her personality shine through.

Contestant applications are due no later than Friday, July 10, 2026.

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* 1. Name of Center:

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* 2. Address:

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* 3. City:

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* 4. State:

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* 5. Zip:

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* 6. Contact Person Name:

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* 7. Contact Person Email:

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* 8. Phone Number:

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* 9. Contestant Full Name:

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* 10. Length of residency at skilled nursing center:

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* 11. Birthdate:

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* 12. Birthplace:

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* 13. Present Age:

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* 14. Number of children/grandchildren:

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* 15. Places where contestant has lived:

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* 16. Occupation(s) throughout lifetime:

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* 17. Hobbies or Special Interests:

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* 18. Life accomplishments:

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* 19. Awards:

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* 20. Church activities:

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* 21. Community activities:

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* 22. Person contestant most admires & why:

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* 23. What contestant enjoys most about their skilled nursing center:

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* 24. Favorite resident activities:

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* 25. Ways contestant continues to help others:

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* 26. Most remarkable event contestant has seen or heard about in their lifetime:

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* 27. Any additional comments/stories you would like to share about the resident.

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* 28. Why contestant wants to be Ms. GHCA:

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* 29. Does the contestant use a wheel chair:

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* 30. Does the contestant use a walker

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* 31. Is the contestant hearing impaired:

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* 32. Contestant Picture:

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* 33. Contestant Video Interview:

I, the undersigned, hereby consent to have my name, image, voice, likeness, biographical information, and statements (collectively, my “Likeness”) captured, photographed, videotaped and/or otherwise recorded by the Georgia Health Care Association/Georgia Center for Assisted Living, its successors, assigns, licensees, agents, and legal representatives (“GHCA/GCAL”). I grant to GHCA/GCAL the right to use my Likeness for any purpose, commercial or non-commercial, as it may see fit, including without limitation the right to publish, promote, distribute, modify, edit, adapt, and make derivative works from any photographs, videotapes, and other recordings that feature or include my Likeness (collectively, the “Materials”). This grant of permission is made on a royalty free, perpetual, irrevocable, non-exclusive basis, and will apply in any media now known or later invented, with or without attribution to me, and with the express understanding that I will not be given a right of approval or advance notice of any particular use of the Materials and/or my Likeness.

I agree that all Materials are the sole property of GHCA/GCAL, and that GHCA/GCAL may copyright any aspect of the Materials. If I should receive any print, negative, or other copy of the Materials, I will not authorize its use by anyone else. I understand that no Materials will be submitted to me for approval, that I will receive no compensation or other consideration for the granting of this permission or of the use of the interview, and that GHCA/GCAL shall be without liability to me for any ill effect resulting from the publication of my Likeness.

To the extent that I make any statement or endorsement about the goods and services offered by GHCA/GCAL, I affirm that my statements reflect my true and accurate beliefs based on my use of and experience with those products and services. I further release GHCA/GCAL from any and all claims for damages for libel, slander, invasion of the right of privacy or any other claim based on the use of my Likeness that is consistent with this Release.

I hereby warrant that I am eighteen years of age or older (or that this release has been signed by my parent/legal guardian), am fully competent to execute this Release, have read this document before signing below, and fully understand its contents, meaning, and impact. In addition, I warrant that my execution of this Release, and GHCA/GCAL’s use of the Materials and/or my Likeness, will not conflict with any other agreement to which I am bound.

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* 34. Name/Signature for Media Release Form

Thank you for submission!

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