Registration Application

July 1, 2024 - October 31, 2024

for the

2025 Miss Juneteenth America Scholarship Pageantry Program™

Registration Information

The registration fee is $450 for new particpants, or $350 for repeat participants, which is payable in installments with the full amount to be paid no later than November 1, 2024, which is the deadline to register. The registration fee covers the cost of participation for the participant, including workshops/activities, reception, the brunch, t-shirt, the Africatown tour, and one souvenir booklet. The registration fee does not cover any lodging fees, which is the responsibility of the parent and/or guardian should you choose to stay at our host hotel using our group rate. Hotel rates will be announced soon. As a friendly reminder, the cost of lodging is not covered by the registration fee. Please note that the registration fee is non-refundable. For your application to be processed, a $50 non-refundable application fee is due at the time of registration, which will be applied towards the registration fee. There are no exceptions!

Partial scholarships may be available. Please contact us at info@missjuneteenth.org to request more information.

Parent/Guardian Acknowledgement

I have read and understand the Rules and Regulations and the Roles and Responsibilities of the crowned Junior Miss Juneteenth America®and/or Teen Miss Juneteenth America® (whichever is applicable), and I would like to submit my child’s registration for participation in the 2025 4th Annual Miss Juneteenth America Scholarship Pageantry Program™. I agree to adhere to all the rules, regulations and guidelines set forth by The Maynard 4 Foundation. I further agree to pay all fees (non-refundable) as required.

Additionally, I consent to any and all video, photography and media coverage during the program and after that is considered connected to or related to this program. I further consent to The Maynard 4 Foundation’s use of my child’s name and images (and likeness) for informational, promotional and any other professional manner deemed appropriate by The Maynard 4 Foundation before, during and after the program. I further agree that all content created for the purpose of the Miss Juneteenth America Scholarship Pageantry Program™ shall be the property of The Maynard 4 Foundation, who shall not be required to submit any images, videos or photographs for review and/or approval prior to usage.

I also agree to hold The Maynard 4 Foundation harmless for any and all liability during my participation in the 2025 program and any other events related to my participation as either a queen or participant of the Miss Juneteenth America Scholarship Pageantry Program™.

By typing your name below, you are acknowledging and agreeing to all of the terms as specified above.

Today's Date

Address

City

State

Zip Code

Your Phone Number

Email Address

Your Personal Social Media URL(s)

Participant's Full Name

Partcipant's Date of Birth

Participant's Address

Participant's City

Participant's State

Participant's Zip Code

Paticipant's Phone Number

Participant's Email Address

Participant's Social Media URL(s)

Participant's School Name

Participant's GPA

Participant's Grade Level

Participant's School Activities

Participant's Extracurricular Activities

Participant's Accomplishments

Participant's Community Service Activities

Participant's Hobbies/Talents

Participant's Career Aspirations Select one profession.

Select the State the Participant's Favorite HBCU is located?

Select Participant's Favorite HBCU in Alabama?

Select Participant's Favorite HBCU in Arkansas?

Select Participant's Favorite HBCU in California?

Select Participant's Favorite HBCU in Delaware?

Select Participant's Favorite HBCU in D.C.?

Select Participant's Favorite HBCU in Florida?

Select Participant's Favorite HBCU in Georgia?

Select Participant's Favorite HBCU in Illinois?

Select Participant's Favorite HBCU in Kentucky?

Select Participant's Favorite HBCU in Louisiana?

Select Participant's Favorite HBCU in Maryland?

Select Participant's Favorite HBCU in Michigan?

Select Participant's Favorite HBCU in Mississippi?

Select Participant's Favorite HBCU in Missouri?

Select Participant's Favorite HBCU in New York?

Select Participant's Favorite HBCU in North Carolina?

Select Participant's Favorite HBCU in Ohio?

Select Participant's Favorite HBCU in Oklahoma?

Select Participant's Favorite HBCU in Pennsylvania?

Select Participant's Favorite HBCU in South Carolina?

Select Participant's Favorite HBCU in Tennessee?

Select Participant's Favorite HBCU in Texas?

Select Participant's Favorite HBCU in Virgin Islands?

Select Participant's Favorite HBCU in Virginia?

Select Participant's Favorite HBCU in West Virginia?

Participant's Favorite Quote

Participant's Selected Historical Figure (Black Female) Black female from the United States that is an Unsung Hero not often discussed and/or as well known to the general public, but information is available via research, including a photo.

Participant's T-Shirt Size

Participant's Food Allergies

Explain with specificity how the participant plan to use the scholarship funds that you earn.

State the nonprofit (must have 501(c)(3) designation) of choice to receive a grant and provide their mission statement and/or website information.

I understand that the non-profit selected must be able to produce a Letter of Determination as provided by the IRS reflecting their 501(c)(3) status. I understand that the non-profit selected must be able to produce a Letter of Determination as provided by the IRS reflecting their 501(c)(3) status. Yes No

I understand that I must submit a headshot of the participant from the waist up wearing a solid colored blouse or dress on a solid white background. I understand that I must submit a headshot of the participant from the waist up wearing a solid colored blouse or dress on a solid white background. T-shirts, multi-colored blouses, low-cut tops, or selfies are not acceptable. Submit photo via email to our branding team at admin@ckiniodesign.com. Yes No

I understand that the information provided on this application will be used to create the participant's bio for event and marketing purposes. I understand that the information provided on this application will be used to create the participant's bio for event and marketing purposes. Yes No

I agree to pay the full registration fee of $450 (non-refundable) for new participants or $350 (non-refundable) for repeat participants no later than November 1, 2024? The application fee due at the time of submission is $50 (non-refundable), which will leave a balance of $300 or $400 unless paid in full at the time of submission. I agree to pay the full registration fee of $450 (non-refundable) for new participants or $350 (non-refundable) for repeat participants no later than November 1, 2024? The application fee due at the time of submission is $50 (non-refundable), which will leave a balance of $300 or $400 unless paid in full at the time of submission. Yes No

How did you hear about the Miss Juneteenth Scholarship Pageantry Program?

Financial Obligation

Registration is $450 (non-refundable) to be paid in full no later than November 1, 2024. Application fee due at the time of submission is $50 (non-refundable), which will leave a balance of $400 unless paid in full at the time of submission. You will be set up on automatic monthly payments to ensure full payment is received no later than November 1, 2024.

ALL FEES ARE NON-REFUNDABLE. You will receive an invoice for the $50 application fee once the application is received by The Maynard 4 Foundation. This must be paid at the time of your application, or it will be rejected. Fees may be paid by credit/debit card, cashier’s check or money order. Cash is not accepted. You will be responsible for paying any transactional fees, if paying electronically.

Make cashier check or money order payable to the following: The Maynard 4 Foundation

You may mail payment and any additional documents as needed to the following:

The Maynard 4 Foundation
200 U.S. Highway 98, Suite 4, #323
Daphne, Alabama 36526

Cash and personal checks are not accepted.

Registration Application

Registration Information

Parent/Guardian Acknowledgement

Financial Obligation

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