Registration for Miss Puerto Rico Pageant

First Name*

Last Name*

Address*

City*

State*

Zip*

Country*

Phone*

Email*

Registration Type*

Current School*

DOB*

Age*

Current Grade*

Place of Birth*

Mother's Name*

Mother's Phone Number

Mother's Email

Mothers Place of Birth

Father's Name

Fathers Place of Birth

Fathers Phone Number

Father's Email

Interest, hobbies and/or clubs you are participating in and that you may want to share with us

Emergency Contact*

Emergency Contact Phone Number*

Relationship*

All information is correct to the best of my knowledge. I also agree to the terms for the 2018 Miss Puerto Rico of Greater Hartford Pageant*

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Total Amount

Payment method

Blue Pay Credit Card Processing

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*