AZCosmeticDocs.Com :: Arizona's Mini Makeover

PARTICIPANT APPLICATION	Print Form to send by mail
Section I: The Basics
1. First Name:*	Middle Name:	Last Name: *
2. Have you ever formally or otherwise changed your name? If so, what other names have you used?

3. Home Street Address:*
4. City: *	State: *	ZIP Code:*
5 Phone (Work):	Phone (Home):	Cellular (If Applicable):
6. Email:*
7. Age (As of Today):	Date of Birth:	Gender: Male: Female:
8. Height:	Weight:
Hair Color:	Eye Color:
9. Are you a legal resident of the United States?	A. Drivers' License #	B. Social Security #

10 Current Occupation (Please Include Company, Title and Dates of Employment)

11 Your Current Marital Status (Select One)
Single
Dating
Married		How Long? How Many Times?
Not Married, But Living With Significant Other		How Long?
Separated		How Long?
Widowed		How Long?
Divorced		How Long?
12 Do You Have Any Children? If So, please list their name(s) and age(s)

13. What is The Highest Level of Education You've Completed (Select One)
High School
Associates College Degree	Major:
Bachelor's College Degree	Major:
Master's College Degree
Professional or Doctoral Degree
14. What School(s) did you attend? (Include the City and State and Years of Attendance)

15. Are You A Member Of Any Professional Performing Art Union? (i.e. AFTRA or SAG)

16. Have You Ever Been Arrested? If So, Tell Us About It? (Include Dates and Jurisdictions)

17. Have You Ever Been Charged With A Crime? If So, Tell Us About It (Include Dates and Jurisdictions)

18. Have You Ever Been Convicted Of A Crime? Is So, Tell Us About It (Include Dates and Jurisdictions)

19. Have You Ever Had A Restraining Order Issued Against You? If So, Tell Us About It? (Include Dates and Jurisdictions)

20 Have You Been Involved In Any Past and/or Pending Litigation? If So, Tell Us About It (Include Dates and Jurisdictions)

Note: Please give us contact information for people whom you give us permission to contact as references, as a means to contact you, or as a means of obtaining additional information about you.
21 Names and Phone Numbers of 2 Closest Friends
a) b)
22 Names and Phone Numbers of 2 Nearest Relatives
a) b)
Section II: Family & Lifestyle
23. Why do you feel you should be chosen to receive the "Mini Makeover?"

24. If you are selected to receive the "Mini Makeover," list everything you would like to have altered?

25 What areas or parts of your body are you most unhappy with? Have you always felt that way? If not, what event changed your image of yourself?

26. In what ways has your physical appearance affected your life?

27. If you were to receive "The Mini Makeover" in what ways would your life be altered?

Section III: Medical
28. Have You Ever Been Treated For Any Serious Physical or Mental Illnesses Within The Last Five (5) Years? (Select One)
Yes No
29. If You Answered "Yes" In Question 37, Please Describe In Detail, Indicating Dates, Diagnosis and Any On-Going Treatments, Prescription Medicines or Difficulties.

30 Have you ever been treated for Depression? In your opinion, what triggered your depression?

31. Are you currently or have you ever taken anti-depressants?

32. Please List Any Allergies You Have (Medications, Food, Hay Fever, Dust, Etc.) And Your Current Treatment For Them (If Any).

33. Have You Ever Been Diagnosed With Alcoholism Or Any Other Drug-Related Addiction? If So, Please Provide More Details Including How Long You've Been In Recovery, If That's The Case.

34. Do you have any sexually transmitted diseases? If so, please describe:

Section IV: Your Chance To Be Creative
35 In A Brief Statement, Tell Us Why We Should Choose You, Over Anyone Else, To Receive The "Mini Makeover"?

36 Besides altering your appearance, what is your biggest dream?

37 Have you ever had any type of plastic or cosmetic surgery? If so, please list specific surgeries and the reasons for those procedures.

38 Is there anyone else you would like to nominate for an Mini Makeover?

39. Upload Two Photos
Face Photo:	Full body Photo:

Section V: Eligibility Requirement, Consents, and Releases
1. You must be a U.S. citizen. 2. You or any of your immediate family members (spouse, ex-spouse, parents, siblings, children) and household members (whether related or not) may not be employees, officers, directors, representatives or agents of New Screen Concepts, New Screen Entertainment, Inc., Lighthearted Entertainment, Greengrass Productions, Inc., American Broadcasting Companies, Inc., The Walt Disney Company, known sponsors of the program or their advertising agencies, any station initially airing the program, and/or their respective parent, subsidiary, or affiliated companies, licensees, partners and assigns. 3. You must never have been convicted of a felony or misdemeanor, other than a minor traffic violation, and have never had a restraining order or other injunctive relief entered against you. There must not be any outstanding criminal warrants for you. 4. You must not have appeared in a prime-time television reality/game show series or are not involved in the current production of any such television show. 5. If selected as a participant you must execute all waivers and release agreements required by the producers or by ABC. 6. You will need to be available for several days for the Makeover process, as well as approximately four to seven weeks thereafter for recoveries (if needed) and participation in a follow-up Makeover . 7. You must be in excellent mental and physical health. 8. You must be willing to submit medical information to the production and submit to a medical examination, psychological examination, and background check. I hereby acknowledge that: (i) I have answered the previous questions honestly and accurately; (ii) I will immediately inform Azcosmeticdocs.com if any information I have provided becomes false or incomplete; (iii) if any of the above information is found to be false or incomplete this will be grounds for dismissal from the participant selection process, and/or from the program currently entitled "The Mini Makeover", if selected; (iv) even if I meet the above eligibility requirements, Azcosmeticdocs.com has no obligation to interview me, and/or select me as a participant; (v) even if I am selected as a participant, Azcosmeticdocs.com has no obligation to conduct the Program or to display it, even if conducted; (vi) all decisions by Azcosmeticdocs.com concerning selection of the participants are final and not subject to challenge or appeal; and (vii) Azcosmeticdocs.com has no obligation to return any materials submitted by me as part of the application whether or not I am selected as a participant. I understand that the Program involves an "Mini Makeover" of the participant which may include, without limitation, cosmetic and/or plastic surgery on the participant. I acknowledge that before participating in the Program, I will consult with my own physician regarding the advisability from a physical and emotional health perspective of my potential participation in the Program. I represent that if I proceed with the participant selection process and am selected to be a participant in the Program, I know of no reason, following consultation with my own physician, why I should not participate in the Program. By submitting this application I hereby consent to the recording, use and reuse by Azcosmeticdocs.com (collectively "Releasees") of my voice, before and after photo's, actions, likeness, name, appearance, biographical material, and any information contained in my application to be a participant in the Program or in any materials submitted by me in connection with my application (collectively "Likeness") as edited, altered, or modified by the Releasees, in any and all media now known or hereafter devised, in any and all versions, worldwide in perpetuity, in or in connection with the Program. I agree the Releasees may use all or any part of my Likeness, and may alter or modify it regardless of whether or not I am recognizable. I further agree that Releasees exclusively own all right, title, and interest (including, without limitation, all copyrights) in and to any photo's that I have provided in connection with my application and any other materials that I have provided or may provide in connection with the Program (the "Materials") including, without limitation, the right to edit, alter or modify the Materials and to use all or part of the Materials and my Likeness in any and all media now known or hereafter devised in any and all versions worldwide, in perpetuity. I further agree that Releasees may use my Likeness and the Materials in connection with any promotion, publicity, marketing or advertisement for the Program. I grant the rights hereunder whether or not I am selected to participate in the Program in any manner whatsoever. I agree to release, defend, indemnify and hold harmless Releasees from any and all claims, actions, lawsuits, liabilities and expenses arising out of or relating to its recording or use of my Likeness and/or the Materials. I agree not to make any claim against Releasees as a result of the recording or use of my Likeness and/or the Materials (including, without limitation, any claim that such use invades any right of privacy and/or publicity). I understand that I will not be paid any money for giving Releasees these rights, or for signing this agreement. I authorize Azcosmeticdocs.com and its designees to investigate, access and collect information about me, about any of the statements made by me in my application, any supporting documents and any other document that I have signed or do sign in connection with my application to be selected as a participant in the Program, or any other written or oral statements I make in connection therewith. I irrevocably authorize Azcosmeticdocs.com and their respective designees to secure information about my experiences from my current and former employers, associates, friends, family members, educational institutions, government agencies, credit reporting agencies, and any references I have provided, and I irrevocably authorize such parties to provide information concerning me. I specifically authorize investigation of my employment record, medical record, and government records, including but not limited to my motor vehicle record, civil record, criminal record and consumer report(s). I agree to execute any authorizations, consents and releases requested from me by Azcosmeticdocs.com and their respective designees in connection with their investigation of me. I hereby unconditionally and irrevocably release and forever discharge all such parties and persons from any and all liabilities arising out of or in connection with any such investigation. I agree to undergo to the extent permitted by law and at the sole discretion of Azcosmeticdocs.com, with no prior notice to me, any physical and mental examinations requested by Producer in connection with my possible selection for and participation in the Program. Such examinations will be conducted by medical personnel of Azcosmeticdocs.com choosing. I acknowledge that I may not be selected to participate or my participation may be discontinued at any time if in the sole and exclusive discretion of Producer and/or its medical experts the results of such tests indicate that I am not physically or mentally fit to participate in the Program. I understand and agree that any physical and/or mental assistance, examinations and/or sessions I may have with any medical personnel retained by or associated with the Program, Azcosmeticdocs.com and its affiliates, does not create a confidential relationship between myself and such medical personnel. Accordingly, I acknowledge and consent to production doctors, psychologists, and other medical personnel communicating with Azcosmeticdocs.com and their designated doctors any diagnoses, prognoses, medical information and/or opinions regarding me. I hereby waive any physician-patient privilege I may have or that may arise with any physicians, psychologists, health care providers (including both physical and mental health care providers), social workers, health care institutions, insurers, and other individuals and entities as a result of my participation in the selection process and/or the Program, and I authorize the release to Azcosmeticdocs.com and designated doctors of all records and information, written, verbal, electronic or otherwise, from any of the above persons and/or entities. I agree to sign any authorizations that Azcosmeticdocs.com or a health care provider deems necessary to facilitate the release of such records and information. Without in any way limiting anything herein, I further hereby release, discharge, relinquish and hold harmless Releasees from any medical care assistance, treatment or services provided to me at any time whether such treatment or services are provided by health care professionals, paramedics, or any other person. I agree to treat all information and material I receive or acquire as part of my participation in the participant selection process for the Program as strictly confidential and to not disclose any such information to any third party. I specifically acknowledge that the financial value of the Program to Azcosmeticdocs.com depends on confidentiality and I agree to be responsible for any and all damages, including consequential damages that Azcosmeticdocs.com and/or any of the Releasees may suffer if I breach this confidentiality provision. I agree to release, defend, indemnify and hold harmless the Releasees and all media and production companies affiliated with or associated with the production, promotion and/or broadcast of the Program and their respective owners,employees, doctors, agents, officers and directors from and against any and all claims, actions, lawsuits, liabilities and expenses arising from or relating to: (a) my participation in the Program including, without limitation, the participant selection process, (b) the use of my Likeness and/or the Materials, (c) any of my acts or statements relating to or in connection with the Program; and (d) any breach of my representations or warranties herein. I understand and agree that all rights under Section 1542 of the California Civil Code and any similar law of any state or U.S. territory, any similar federal law, or any similar common law or principle of similar effect, are hereby expressly waived. I acknowledge and understand that said section reads as follows: "1542. Certain claims not affected by general release. A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the tims of executing the release, which if known by him must have materially affected his settlement with the debtor." I acknowledge that I may hereafter discover claims in addition to the ones released herein, and I hereby release Releasees for any such unknown or unsuspected claims. I acknowledge that in the event of a breach of this Consent and Release by Azcosmeticdocs.com or any third party, the damage, if any, caused me will not be irreparable or otherwise sufficient to entitle me to seek injunctive or other equitable relief. I acknowledge that my rights and remedies in any such event will be strictly limited to the right, if any, to recover damages in an action at law, and I acknowledge and agree that I will not have the right to rescind this Release or any of Releasees' rights hereunder, nor the right to enjoin the production, exhibition or other exploitation of the Program, or any subsidiary or allied rights with respect thereto, or any other results and proceeds hereunder.
I have read, understand, and agree with the foregoing. *
Thank you for your time and effort in completing the form. Deadline: This is a rolling application process. We will post the deadline on the web site 10 days before we stop accepting applications. All Photos will be retained by Azcosmeticdocs.com and become the property of Azcosmeticdocs.com and will not be returned to you whether or not you are selected as a contestant. Any expenses you incur during the application process including postage, shipping, materials preparation (, photos, etc.) are your sole responsibility. We will not reimburse you for these expenses. Only one entry per person is allowed. All decisions of Azcosmeticdocs.com are final and absolute and not subject to inquiry. Applications will only be considered if they are complete. Complete applications consist of the following: Completed Application Form 2 photos one clear face photo and a full body shot.

Section I: The Basics

Section II: Family & Lifestyle

Section III: Medical

Section IV: Your Chance To Be Creative

Section V: Eligibility Requirement, Consents, and Releases