Having troubles with the application? Have no fear, help is here!
Please contact Mike at mikemcgrath@charter.net if there are problems submitting this application.
Enter your first name, or the name you like to be called by. This field is required.
Enter your middle name, or middle initial. This field is optional and may be skipped.
Enter your last name. This field must be entered.
Enter your house, or apartment number and the street you live on. This is where all mail from Ms. Wheelchair MD will be sent. This field must be entered.
Enter the city where you reside. This city should be for the street address you listed in the Street Address field. This field must be entered.
Enter the State for the address you listed above. Remember you must be a Maryland resident to compete. This field is required.
Enter your complete home phone number including area code. The format you enter does not matter. This field must be entered. If you only have a cell phone, than it may be entered in this field.
Enter your complete work phone number including area code. The format you enter does not matter. This field is optional.
Enter your complete cell phone number including area code. The format you enter does not matter. This field is optional.
Enter your fax number including area code. The format you enter does not matter. This field is optional.
Enter your complete email address. This field must be entered. If the format of the email is incorrect you may receive an error message upon submitting the form.
Enter first name of your emergency contact. This field is required.
Enter last name of your emergency contact. This field must be entered.
Enter house, or apartment number and the street your emergency contact lives on. This field must be entered.
Enter your emergency contact's complete home phone number including area code. The format you enter does not matter. This field must be entered.
Enter your emergency contact's complete work phone number including area code. The format you enter does not matter. This field is optional.
Enter your emergency contact's complete cell phone number including area code. The format you enter does not matter. This field is optional.
Enter your emergency contact's email address. This field is optional.
Please enter your birthday. You may enter your birthday in any format. The desired format is month/day/year. This is field must be entered.
Please enter your age using whole numbers, for example 26. An error will appear when submitting the application if age is less than 14 or greater than 60 years. This field is required.
Please enter your occupation. If you are a student you may enter student and list your school and or major. This field is required.
Enter your number of children. Include those living and not living with you. Enter their names and ages. These fields are not required. Children's names and ages are required if the number of children field is filled in.
Select your marital status from the dropdown list. You must enter your marital status.
Enter your spouse or significant other in this field. This is an optional field.
Please enter your hobbies. This field is required.
Select your primary mode of transportation. If you use another form of transportation, select Other, and specify what it is. If you walk, ride a bike, skate board, roller blade, horseback, ice skate, sled dogs, snow mobile, fly, boat, ski, or snowboard let us know. This question requires an answer. If you choose Other, please specify in the text box provided.
What disability do you have? How does it affect you? This field is required.
Electric, manual, scooter, or anything else. This field is required.
Select Yes if you take medication, or select No if you do not. This field is required. If you take medication please specify what medication you take in the box below. This is required if you select Yes.
Select Yes if you have allergies, or select No if you do not. This field is required. If you have allergies please specify what allergies you have in the box below. This is required if you select Yes.
Select Yes if you have a service animal. Select No if you do not have a service animal. This field is required.
Please list any company name, contact person, address, phone number, email address, and web site of those that have helped sponsor you. It can be anyone that has funded you or helped you get to the pageant.
List your accomplishments focusing on any awards, honors, and degrees you have received.
Explain what you do in the community and how you advocate for those in your community. Include memberships, offices held, public speaking, etc. Does not have to be disability related.
You will be asked to give a three minute speech outlining your platform including its significance to you and the disability community. Enter what you are interested in for your platform. This will be the focus of your campaign. You do not have to enter your speech here, just enter some idea of what you will talk about. This field is required.
This field is required.
Please contact Mike at mikemcgrath@charter.net if there are problems submitting this application.