Rebecca Peterman Photography

2012-2013 Model Search Entry Form

Date of submission_______________________________________________________________

Name__________________________________________________________________________

Age___________________  Birth date________________________________________________

Name of Parent or Guardian_________________________________________________________

Email Address____________________________________________________________________

Home Phone #_______________ Work #_____________________  Cell #___________________

Address________________________________________________________________________

City_______________________________  State___________  Zip_________________________

Email Address____________________________________________________________________

School Name_____________________________________________________________________

Extracurricular Activities_____________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Favorite Food______________________________________________________________________

Favorite Activity____________________________________________________________________

Favorite Color______________________________________________________________________

Mail your completed entry form and $10 donation check made out to "Operation Smile" to:

Rebecca Peterman Photography

301 Oakcliff Street

Hot Springs, AR  71901

We will contact you to schedule your photo shoot time.