Tuesday, July 12, 2011  McMillan Park, Mt. Pleasant, Iowa

Contestant's Name:		Parent or Guardian (if under 18):
Address:		Phone:	() -
Birth Date:	-  -	Age:
SSN (not required, but will be needed if you win):   -  -
Type of Performance:  VocalDanceOther (brief explanation)
Group Acts (list all members and ages):
Name:    Age:		Name:    Age:
Name:    Age:		Name:    Age:
Name:    Age:		Name:    Age:
Does your act require a piano?  YesNo